Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on the simplification of the drug regimen for secondary cardiovascular prevention.

The issue of suboptimal drug regimen adherence in secondary cardiovascular prevention presents a significant barrier to improving patient outcomes. To address this, the utilization of drug combinations, specifically single pill combinations (SPCs) and polypills, was proposed as a strategy to simplify treatment regimens. This approach aims to enhance treatment accessibility, affordability, and adherence, thereby reducing healthcare costs and improving patient health. The document is an Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on simplifying drug regimens for secondary cardiovascular prevention. It discusses the underuse of treatments despite available, effective, and accessible options, highlighting a significant gap in secondary prevention across different socio-economic statuses and countries. The statement explores barriers to implementing evidence-based treatments, including patient, healthcare provider, and system-related challenges. The paper also reviews international guidelines, the role of SPCs and polypills in clinical practice, and their economic impact, advocating for their use in secondary prevention to improve patient outcomes and adherence.

Treatment of amyloidosis: present and future.

Cardiac amyloidosis (CA) is an infiltrative heart disease resulting from the deposition of amyloid fibrils in the interstitial spaces of the myocardium. The two main forms of CA are represented by light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR) in the two forms familial or variant or wild-type or senile. Although considered a rare disease, CA is an underdiagnosed disease. Delay in diagnosis has a negative impact on the prognosis, delaying the initiation of specific therapy. The treatment of both forms of CA is based on: (i) prevention and slowing of the generation and deposition of amyloid fibrils and (ii) supportive care of complications. The main success of recent years has been the development of effective therapies that have been possible thanks to the understanding of the pathophysiology of amyloidosis. For the AL form, new therapeutic combinations between a proteasome inhibitor and a monoclonal antibody have been developed. For ATTR forms, the main strategies are transthyretin (TTR) production 'silencers' and TTR tetramer stabilizers. Supportive care of patients with CA involves various clinical aspects including treatment of heart failure, arrhythmias, conduction disturbances, thrombo-embolism, and the concomitant presence of aortic stenosis.

Selection of patients eligible for implantable cardioverter defibrillator: beyond left ventricular ejection fraction.

The selection of patients eligible for implantable cardioverter defibrillator (ICD), in primary prevention, is a critical moment in the management of the patients with cardiomyopathies as it needs a right balance of the patients' arrhythmic risk and the risks related to the implantation, as well as the device costs. Several data indicate that left ventricular ejection fraction alone is not a sufficient criterion for a proper identification of patients who could benefit most from ICD. Numerous findings show that genetic analysis and characterization of myocardial fibrosis with magnetic resonance imaging allow an important improvement of this process.

Moderate gradient severe aortic stenosis: diagnosis, prognosis and therapy.

Aortic stenosis (AS) is defined as severe in the presence of: mean gradient ≥40 mmHg, peak aortic velocity ≥4 m/s, and aortic valve area (AVA) ≤1 cm2 (or an indexed AVA ≤0.6 cm2/m2). However, up to 40% of patients have a discrepancy between gradient and AVA, i.e. AVA ≤1 cm2 (indicating severe AS) and a moderate gradient: >20 and <40 mmHg (typical of moderate stenosis). This condition is called 'low-gradient AS' and includes very heterogeneous clinical entities, with different pathophysiological mechanisms. The diagnostic tools needed to discriminate the different low-gradient AS phenotypes include colour-Doppler echocardiography, dobutamine stress echocardiography, computed tomography scan for the definition of the calcium score, and recently magnetic resonance imaging. The prognostic impact of low-gradient AS is heterogeneous. Classical low-flow low-gradient AS [reduced left ventricular ejection fraction (LVEF)] has the worst prognosis, followed by paradoxical low-flow low-gradient AS (preserved LVEF). Conversely, normal-flow low-gradient AS is associated with a better prognosis. The indications of the guidelines recommend surgical or percutaneous treatment, depending on the risk and comorbidities of the individual patient, both for patients with classic low-flow low-gradient AS and for those with paradoxical low-flow low-gradient AS.

Clinical characteristics, treatment, trajectories and outcome of patients with dilated cardiomyopathy in a national heart failure registry.

BACKGROUND: Available data on the clinical characteristics and prognosis of patients with heart failure (HF) due to dilated cardiomyopathy (DCM) derive mainly from tertiary care centres for cardiomyopathies or from drug trial sub-studies, which may entail a referral bias. METHODS: From 2008 to 2021, we enrolled in a nationwide HF Registry 1886 DCM patients and 3899 with ischemic heart disease (IHD). RESULTS: Patients with DCM were younger, more often female, had more commonly recent onset HF, left bundle branch block, and showed higher LV end-diastolic volume and lower LVEF than IHD. With respect to IHD, DCM patients received more often mineralocorticoid receptor antagonists, renin angiotensin system inhibitors and betablockers, the latter more commonly at doses ≥50% of target, and triple guideline-directed medical therapy (GDMT) (adjusted OR 1.411, 95% CI 1.247-1.595, p < .0001). During one-year follow-up, 819 patients (14.2%) died or were hospitalized for HF [187 (9.9%) DCM, 632 (16.2%) IHD]; DCM was associated with lower risk of the combined end-point (adjusted HR 0.745, 95% CI 0.625- 0.888, p = .0011). Among the 1954 patients with 1-year echocardiograms available, 1483 had LVEF≤40% at baseline; of these,166 (30.6%) DCM and 165 (17.5%) IHD improved their LVEF to >40% (p < .0001). DCM aetiology was associated with higher likelihood of LVEF improvement (adjusted OR 1.722, 95% CI 1.328 -2.233, p < .0001). CONCLUSIONS: DCM patients have a different clinical profile, greater uptake of GDMT and better outcomes than IHD subjects. A comprehensive management approach is needed to further address the risk of unfavorable outcomes in DCM.

[The IN-HF Registry: the history and the scientific production for the Italian cardiology community]. / Il programma IN-HF: la storia e la produzione scientifica a favore della comunità cardiologica italiana.

The Italian Network on Congestive Heart Failure (IN-CHF) project, later known as IN-HF Online, was launched in 1995 to provide the Italian cardiology community with a digital tool, standardized across the country, for managing outpatients with heart failure (HF), that enabled the creation of a database for clinical, educational and scientific purposes. During its almost three decades of activity, this observational research program has achieved highly positive scientific results. Indeed, IN-HF fostered professional relationships among individuals working in different centers, established a cultural network for the care of HF patients, periodically updated on the scientific advances, and allowed the assessment of several clinical, epidemiological, and prognostic features. These findings have been published in numerous national and international journals, as summarized in the present overview.

[ANMCO Scientific statement on combination therapies and polypill in secondary prevention]. / Scientific statement ANMCO sulla semplificazione del regime terapeutico farmacologico in prevenzione secondaria.

The issue of suboptimal drug regimen adherence in secondary cardiovascular prevention presents a significant barrier to improving patient outcomes. To address this, the utilization of drug combinations, specifically single pill combinations (SPCs) and polypills, was proposed as a strategy to simplify treatment regimens. This approach aims to enhance treatment accessibility, affordability, and adherence, thereby reducing healthcare costs and improving patient health. The document is an ANMCO scientific statement on simplifying drug regimens for secondary cardiovascular prevention. It discusses the underuse of treatments despite available, effective, and accessible options, highlighting a significant gap in secondary prevention across different socioeconomic statuses and countries. The statement explores barriers to implementing evidence-based treatments, including patient, healthcare provider, and system-related challenges. The paper also reviews international guidelines, the role of SPCs and polypills in clinical practice, and their economic impact, advocating for their use in secondary prevention to improve patient outcomes and adherence.

[ANMCO Position paper: Colchicine as a therapeutic agent in coronary syndromes]. / Position paper ANMCO: La colchicina come agente terapeutico nelle sindromi coronariche.

With the growing knowledge about the role of inflammatory processes in the pathogenesis of atherosclerotic lesions, inflammation has been identified as a cardiovascular risk factor and therapeutic target to reduce the residual risk in patients with atherosclerotic disease. Several therapeutic agents with anti-inflammatory action have been tested to evaluate their efficacy and safety in the context of atherosclerotic cardiovascular diseases. Among these, colchicine, a drug with multiple therapeutic effects including anti-inflammatory action, in randomized clinical trials conducted in the setting of atherosclerotic cardiovascular disease secondary prevention, significantly reduced the risk of adverse cardiovascular events.This position paper of the Italian Association of Hospital Cardiologists (ANMCO) summarizes the main biological mechanisms through which colchicine contributes to the inhibition of inflammatory processes that increase the atherosclerotic cardiovascular risk. Furthermore, the document reports the available evidence on clinical impact of colchicine treatment in the reduction of residual cardiovascular risk in chronic and acute coronary syndromes. Finally, practical information is provided regarding the use of this drug in this specific clinical setting, emphasizing precautions and possible side effects.

[ANMCO Position paper: Evidence and practical indications for the use of low-dose rivaroxaban in stable coronary artery disease and peripheral artery disease]. / Position paper ANMCO: Evidenze e indicazioni pratiche per l'impiego di rivaroxaban a bassa dose nella malattia coronarica stabile e nell'arteriopatia periferica.

In patients with atherosclerotic disease, the occurrence of atherothrombotic events is the main determinant of morbidity and mortality. Growing evidence suggests the involvement of the coagulation pathway in the atherosclerotic process and the benefit of antithrombotic agents, such as direct oral anticoagulants, which interfere with both platelet aggregation and the coagulation cascade. The COMPASS trial has shown that in patients with stable coronary artery disease (CAD) or peripheral artery disease (PAD), low-dose rivaroxaban (2.5 mg twice daily) added to acetylsalicylic acid (ASA) 100 mg reduces major vascular events and mortality, with an increase in major bleeding but not in fatal bleeding or involving a critical organ. The reduction in major cardiovascular events has been confirmed in the overall population with CAD and in both patients with and without a previous percutaneous coronary revascularization, and also in patients with previous coronary bypass surgery. In patients with PAD, the combination of rivaroxaban 2.5 mg twice daily and ASA was found to reduce both major adverse cardiovascular events and major adverse limb events, including major limb amputations. In clinical practice, the use of rivaroxaban 2.5 mg co-administered with ASA has been approved in both patients with CAD and symptomatic PAD at high risk of ischemic events. However, in Italy, the national health system reimbursement is provided only for patients with PAD. In patients treated with rivaroxaban 2.5 mg, assessment and monitoring of bleeding risk is crucial to achieve the maximum clinical benefit.

Different apparent prognostic value of hsCRP in type 2 diabetic and nondiabetic patients with acute coronary syndromes.

BACKGROUND: C-reactive protein (CRP) is an established prognostic marker in acute coronary syndromes (ACS); however, no study has specifically addressed its prognostic role in type 2 diabetes with ACS. We evaluated the prognostic role of CRP separately in diabetic and nondiabetic patients with ACS. METHODS: We enrolled 251 patients with unstable angina and measured serum concentrations of high sensitivity (hs)CRP. Ninety-seven patients underwent coronary angiography with evaluation of atherosclerotic disease severity and extent by Bogaty score. Assessed endpoint was the combined occurrence of myocardial infarction (MI) and death at 1 year. RESULTS: No significant differences were found in hs-CRP between patients with and without diabetes. By Cox regression, hsCRP was not associated with 1-year follow-up events in diabetic patients but was strongly associated with events in nondiabetic patients (P = 0.0012). Coronary angiography exhibited a higher extent index in patients with diabetes than in those without (P = 0.04). hsCRP concentrations were not associated with angiographic atherosclerotic burden. By Cox analysis, hsCRP and extent score were associated with events in patients who underwent coronary angiography (P < 0.001 and P = 0.034, respectively). In nondiabetic patients, hsCRP was the only predictor of events at 1-year follow-up (P < 0.001), whereas in diabetic patients, hsCRP was not associated with events and a weak association was observed for extent score (P = 0.06). CONCLUSIONS: Our study suggests that different pathophysiological mechanisms may be responsible for MI and death in unstable angina patients with or without diabetes and that severity of coronary artery disease plays a major role in diabetes (and inflammation in the absence of diabetes).

Osteoprotegerin and B-type natriuretic peptide in non-ST elevation acute coronary syndromes: relation to coronary artery narrowing and plaques number.

BACKGROUND: To analyse osteoprotegerin (OPG), and B-type natriuretic peptide (BNP) levels in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), in relation to clinical presentation and to coronary atherosclerosis diffusion. OPG has been found in several tissues, including the cardiovascular system, BNP is selectively produced by myocardial cells. METHODS: 178 consecutive patients were classified in three groups: stable angina (SA), unstable angina/non-ST elevation myocardial infarction (NSTE-ACS) and control group, measuring OPG and BNP at hospital admission. We compared both biomarkers in relation to the number of coronary narrowed vessels (1-, 2- , 3- or 4- vessels disease), and to the stenoses degree by Duke Jeopardy score. RESULTS: OPG levels were higher in patients respect to controls (p<0.0001). Patients with SA showed more elevated levels than controls (2.6+/-1.2 vs 7.4+/-5.0 pmol/l p<0.01). However patients with NSTE-ACS had higher OPG level with respect to SA patients (11.8+/-7.1 pmol/l p<0.001). A positive relation was found between OPG levels and number of coronary plaques by Duke Jeopardy score (r=0.65). BNP levels were higher in patients with NSTE-ACS respect to controls and SA patients (p<0.001). Besides, BNP was significantly higher in multivessels vs 1-vessel disease (p<0.001). CONCLUSIONS: Patients with NSTE-ACS show high OPG levels. OPG increase seems related to the number of plaques in the coronary vessels, suggesting its involvement in the coronary disease progression. BNP is also increased during NSTE-ACS and more associated to coronary narrowing.

Modulation of CD4(+)CD28null T lymphocytes by tumor necrosis factor-alpha blockade in patients with unstable angina.

BACKGROUND: Tumor necrosis factor-alpha (TNF-alpha) is a proinflammatory cytokine that favors the expansion of CD4(+)CD28null T cells, an aggressive and unusual proinflammatory lymphocyte subset frequently observed in patients with unstable angina (UA). The purpose of the present ex vivo study was to evaluate whether inflammation in patients with UA may be modulated by selective blockade of TNF-alpha. METHODS AND RESULTS: Peripheral blood samples were collected from 17 patients with UA (Braunwald's class IIIB). CD4(+)CD28null T cells were assessed by flow cytometry and expressed as a percentage of all CD4+ T cells after 24 hours of incubation of whole blood with and without increasing doses (0.1, 1, 10, and 100 microg/mL) of infliximab, an anti-TNF-alpha monoclonal antibody. In addition, CD28 expression was assessed and expressed as mean fluorescence intensity (geometric mean of the CD28 fluorescence value on all CD4+ T cells). CD4(+)CD28null T-cell percentage decreased from a median of 6.2% (range, 1.2% to 23.9%) to 4.9% (range, 1.1% to 21.9%), 4.5% (range, 1.1% to 21.6%), and 4.1% (range, 0.4% to 21.4%) after incubation with 1, 10, and 100 microg/mL of infliximab (P for trend=0.043). Analysis of CD28 mean fluorescence intensity showed that the expression of CD28 on cell surface significantly increased after incubation with increasing doses of infliximab (P for trend=0.03). CONCLUSIONS: The findings of this ex vivo study show that CD4(+)CD28null T-cell expansion in patients with UA may be reduced by selective TNF-alpha blockade. Further studies are warranted to evaluate the clinical benefit of CD4(+)CD28null T-cell modulation.

Prognostic significance of myocardial ischemia during dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus and no prior history of coronary events.

The prognostic significance of myocardial ischemia assessed by dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus who have no previous coronary artery disease remains unclear. We assessed the value of dobutamine stress echocardiography for risk stratification in 161 asymptomatic patients with type 2 diabetes (mean 62 +/- 12 years of age; 96 men) who had no previous myocardial infarction or revascularization. End point during follow-up was hard cardiac events (cardiac death and nonfatal myocardial infarction). Ischemia was detected in 45 patients (28%). During a median follow-up of 5 years, 40 patients (25%) died (18 cardiac deaths) and 7 patients had nonfatal myocardial infarction (25 hard cardiac events). An abnormal dobutamine stress echocardiogram was associated with a higher mortality compared with a normal dobutamine stress echocardiogram (p = 0.03). In an incremental multivariate analysis model, clinical predictors of hard cardiac events were age and hypercholesterolemia. Ischemia was incremental to the clinical parameters. In conclusion, myocardial ischemia is an independent predictor of cardiac events in asymptomatic diabetic patients with no previous coronary artery disease.

1059G/C polymorphism within the exon 2 of the C-reactive protein gene: relationship to C-reactive protein levels and prognosis in unstable angina.

OBJECTIVE: Patients with unstable angina (UA) and high C-reactive protein (CRP) have increased cardiovascular risk. Whether genetic factors such as the synonymous 1059G/C polymorphism within the exon 2 of the human CRP gene determine CRP levels and outcome is unclear. METHODS: In 105 consecutive patients with UA, we assessed the CRP 1059G/C polymorphism, CRP plasma levels and interleukin-6 production after in-vitro stimulation of whole blood with lipopolysaccharide (1 ng/ml). Coronary events during a 24-month follow-up were recorded. RESULTS: CRP levels (median, range) were significantly lower among C-allele carriers (2.3 mg/l, 0.5-26.9) than among GG homozygotes (5.9 mg/l, 0.8-72.12, P=0.009). Interleukin-6 production was lower in C-allele carriers (1645 pg/ml, 832.0-9522) than in GG homozygotes (3929 pg/ml, 670.8-10 582), (P=0.085). At follow-up, 1059C-allele carriers experienced fewer coronary events than 1059GG homozygotes (13 vs. 47%, P=0.021). At multivariable analysis, a CRP level >3 mg/l, but not the 1059G/C polymorphism, was an independent predictor of coronary events (odds ratio 10.04, 95% confidence interval 2.84-35.44, P=0.0002). CONCLUSION: This study shows that the CRP synonymous 1059G/C polymorphism affects CRP levels. No independent association was, however, observed between this polymorphism and clinical outcome in UA.

Prognostic significance of left anterior hemiblock in patients with suspected coronary artery disease.

OBJECTIVES: This study was designed to assess the functional and prognostic significance of left anterior hemiblock (LAHB) in patients with no history of myocardial infarction referred for dobutamine stress echocardiography (DSE). BACKGROUND: The significance of isolated LAHB in patients with suspected coronary artery disease (CAD) is unclear. METHODS: We studied 1,187 patients with suspected CAD and no history of myocardial infarction who underwent DSE and were followed for occurrence of cardiac death. RESULTS: Left anterior hemiblock was detected on baseline electrocardiogram in 159 patients (13%). Ischemia occurred more frequently in patients with LAHB (43% vs. 33%, p = 0.02). During a mean follow-up of 5.0 +/- 2.5 years, 125 patients (11%) died of cardiac causes. The annual cardiac death rate was 4.9% in patients with LAHB and 1.9% for patients without (p < 0.0001). Patients with both LAHB and an abnormal DSE had the highest annual cardiac death rate (6.3%). In a Cox multivariable analysis, independent predictors of cardiac death were age, smoking, history of heart failure, diabetes, and ischemia. Left anterior hemiblock was independently associated with increased risk of cardiac death among patients with normal DSE (hazard ratio 1.8, 95% confidence interval 1.1 to 3.8) and in patients with abnormal DSE (hazard ratio 1.7, 95% confidence interval 1.1 to 2.7). CONCLUSIONS: In patients with suspected CAD referred for stress testing, LAHB is associated with increased risk of cardiac death. This risk is persistent after adjustment for major clinical data and abnormalities on the stress echocardiogram. Therefore, isolated LAHB should not be considered a benign electrocardiographic abnormality in these patients.

Seven-year follow-up after dobutamine stress echocardiography: impact of gender on prognosis.

OBJECTIVES: The aim of this study was to investigate the effects of gender on long-term prognosis of patients undergoing dobutamine stress echocardiography (DSE). BACKGROUND: Gender differences in the predictors of outcome among patients with known or suspected coronary artery disease undergoing DSE have not been adequately studied. METHODS: We studied 2,276 men and 1,105 women with known or suspected coronary artery disease who underwent DSE. Follow-up events were cardiac death and nonfatal myocardial infarction (MI). RESULTS: Dobutamine stress echocardiography was normal in 687 men (30%) and 483 women (44%) (p <0.0001). Ischemia on DSE was present in 1,194 men (52%) and 416 women (38%) (p <0.001). During a mean follow-up of 7 +/- 3.4 years, there were 894 (26%) deaths (442 attributed to cardiac causes) and 145 (4%) nonfatal MIs. The annual cardiac event rate was 2.5% in men and 1.2% in women with normal DSE. Independent predictors of cardiac events in patients with normal DSE using a Cox proportional hazards regression analysis were male gender (hazard ratio [HR]: 1.7 [range 1.1 to 2.8]), age (HR: 1.02 [range 1.01 to 1.04]), history of heart failure (HR: 3.4 [range 1.5 to 7.9]), previous MI (HR: 1.7 [range 1.1 to 2.8]), and diabetes (HR: 2.4 [range 1.3 to 4.5]). Independent predictors of cardiac events in patients with an abnormal DSE were age (HR: 1.03 [range 1.02 to 1.04]), history of heart failure (HR: 1.7 [range 1.3 to 2.1]), diabetes (HR: 1.4 [range 1.1 to 1.8]), heart rate at rest (HR: 2.8 [range 1.4 to 5.8]), wall motion abnormalities at rest (HR: 1.06 [range 1.04 to 1.09]), and ischemia on DSE (HR: 1.04 [range 1.02 to 1.07]). Myocardial ischemia was an independent predictor of cardiac events in both men and women. CONCLUSIONS: Dobutamine stress echocardiography provides independent prognostic information in both men and women. In patients with normal DSE, gender is independently associated with cardiac events. The outcome of patients with abnormal DSE is not related to gender, after adjusting for stress echocardiographic abnormalities.

Impact of diabetes mellitus on prediction of clinical outcome after coronary revascularization by 18F-FDG SPECT in patients with ischemic left ventricular dysfunction.

UNLABELLED: Nuclear imaging using (18)F-FDG is an established method for the noninvasive assessment of myocardial viability. Data on the value of (18)F-FDG imaging in patients with diabetes mellitus are scarce. The aim of this study was to assess whether, in patients with diabetes mellitus and ischemic left ventricular (LV) dysfunction, (18)F-FDG imaging can predict improvement of LV function and heart failure symptoms after coronary revascularization. METHODS: A total of 130 consecutive patients with ischemic LV dysfunction who were already scheduled for surgical revascularization were studied; 34 of the patients had diabetes mellitus. All patients underwent radionuclide ventriculography to assess left ventricular ejection fraction (LVEF), resting 2-dimensional echocardiography to identify dysfunctional myocardial tissue, and dual-isotope (18)F-FDG/(99m)Tc-tetrofosmin SPECT after oral administration of acipimox. Nine to 12 mo after coronary revascularization, radionuclide ventriculography and echocardiography were repeated. An improvement in LVEF by at least 5% was considered significant. RESULTS: (18)F-FDG SPECT demonstrated that 610 (50%) of 1,212 dysfunctional segments were viable. Patients with and without diabetes mellitus had a comparable number of dysfunctional but viable segments per patient. Also, the number of patients with a substantial amount of dysfunctional but viable myocardium (>or=4 viable segments) was comparable between the groups with and without diabetes mellitus. The presence of substantial viability on (18)F-FDG SPECT was predictive of improvement in LVEF and heart failure symptoms postoperatively (sensitivity and specificity of 82% and 89%, respectively, in patients with diabetes and 83% and 93%, respectively, in patients without diabetes; not statistically significant). CONCLUSION: (18)F-FDG SPECT is practical for routine assessment of myocardial viability in patients with ischemic LV dysfunction with or without diabetes mellitus. Patients with substantial myocardial viability on (18)F-FDG SPECT have a high probability of improvement of LV function and symptoms after coronary revascularization, irrespective of the absence or presence of diabetes mellitus.

Comparison between contrast echocardiography and magnetic resonance imaging to predict improvement of myocardial function after primary coronary intervention.

The relative merits of myocardial contrast echocardiography (MCE) and magnetic resonance imaging (MRI) to predict myocardial function improvement after percutaneous coronary intervention have not been evaluated until now. We studied 35 consecutive patients with acute myocardial infarction who underwent percutaneous coronary intervention using MCE and MRI and first-pass imaging for evaluation of myocardial perfusion. Delayed-enhanced MRI was included as another method to differentiate viable from infarcted tissue. MCE was performed by power modulation and intravenous Sonovue. A 16-segment model of the left ventricle was used to analyze all myocardial contrast echocardiograms and magnetic resonance images. At 60 days of follow-up, MCE showed improvement of function in 115 of 192 (60%) dysfunctional segments. The sensitivity, specificity, and accuracy for the prediction of functional improvement were comparable among MCE (87%, 90%, and 88%), first-pass MRI (87%, 60%, and 79%), and delayed-enhancement MRI (75%, 100%, and 82%, respectively, all p = NS). In conclusion, MCE and MRI allowed for prediction of myocardial function improvement after percutaneous coronary intervention. MCE had a comparable accuracy and, as a bedside technique, may be an alternative tool in the acute phase of acute myocardial infarction.

Prognostic implications of a normal stress technetium-99m-tetrofosmin myocardial perfusion study in patients with a healed myocardial infarct and/or previous coronary revascularization.

Previous studies have shown a good outcome for patients who present with normal findings on stress myocardial perfusion imaging. Currently, the prognostic implications of a normal study in patients who have a history of coronary artery disease (CAD) are not clear. This study investigated the long-term prognosis after a normal finding on stress technetium-99m (Tc-99m)-tetrofosmin single-photon emission computed tomography in patients with a history of CAD. The study included 147 consecutive patients with a history of CAD (previous myocardial infarction and/or myocardial revascularization), who underwent exercise bicycle or high-dose dobutamine-atropine stress Tc-99m-tetrofosmin single-photon emission computed tomography, and had normal perfusion results during stress and at rest. Follow-up was completed in all patients. During a follow-up of 6.5 +/- 1.9 years, 20 patients (14%) died, 10 (7%) of whom died due to cardiac causes, and 12 (8%) had a nonfatal myocardial infarction. Annual cardiac death rates were 0.5% during the first 3 years of follow-up and 1.3% in the subsequent 3 years. Independent predictors of cardiac death were male gender, rate-pressure product at rest, and rate-pressure product at peak stress. In conclusion, patients who have a history of CAD have a very low cardiac death rate during the 3 years after a normal finding on stress Tc-99m-tetrofosmin single-photon emission computed tomography. Repeated testing should be reconsidered 3 years after the initial evaluation and when a change in symptoms or clinical condition occurs.

Benefits of coronary revascularisation in diabetic and non-diabetic patients with ischaemic cardiomyopathy: role of myocardial viability.

BACKGROUND: Diabetes mellitus in patients with coronary artery disease is associated with poor outcome. In this study, the relation between myocardial viability, diabetes, coronary revascularisation and outcome was evaluated. METHODS: 129 patients (31 diabetic, 98 non-diabetic) with ischaemic cardiomyopathy underwent dobutamine stress echocardiography to assess myocardial viability. Patients with >or=4 viable segments were defined as viable and patients with <4 viable segments as nonviable. Left ventricular ejection fraction (LVEF) was assessed before and 9-12 months post-revascularisation. At the same time-points, LV volumes were measured to evaluate LV remodelling. Finally, cardiac events were noted during 5-year follow-up. RESULTS: The extent of viable myocardium was comparable between diabetic and non-diabetic patients. After revascularisation, LVEF increased >or=5% in 44% of diabetic and in 40% of non-diabetic patients. LVEF only improved in patients with viable myocardium. Ongoing LV remodelling occurred in 36% and 35% of diabetic and non-diabetic patients respectively, and was related to non-viability, whereas viability protected against ongoing LV remodelling, both in diabetic and non-diabetic patients. Viability was the only predictor of survival after revascularisation. CONCLUSIONS: Diabetic, viable patients with ischaemic LV dysfunction exhibit improvement in LVEF post-revascularisation with prevention of ongoing LV remodelling, similar to non-diabetic patients. Myocardial viability was also the only predictor of long-term outcome.