Impact of body mass index on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: Insights from the ELDERLY ACS 2 trial.

BACKGROUND AND AIM: Elderly patients are at increased risk of hemorrhagic and thrombotic complications after an acute coronary syndrome (ACS). Frailty, comorbidities and low body weight have emerged as conditioning the prognostic impact of dual antiplatelet therapy (DAPT). The aim of the present study was to investigate the prognostic impact of body mass index (BMI) on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study comparing low-dose (5 mg) prasugrel vs clopidogrel among elderly patients with ACS. METHODS AND RESULTS: Our population is represented by 1408 patients enrolled in the Elderly-ACS 2 trial. BMI was calculated at admission. The primary endpoint of this analysis was cardiovascular (CV) mortality. Secondary endpoints were all-cause death, recurrent MI, Bleeding Academic Research Consortium (BARC) type 2 or 3 bleeding, and re-hospitalization for cardiovascular reasons or stent thrombosis within 12 months after index admission. Patients were grouped according to median values of BMI (

Comparison of Reduced-Dose Prasugrel and Standard-Dose Clopidogrel in Elderly Patients With Acute Coronary Syndromes Undergoing Early Percutaneous Revascularization.

BACKGROUND: Elderly patients are at elevated risk of both ischemic and bleeding complications after an acute coronary syndrome and display higher on-clopidogrel platelet reactivity compared with younger patients. Prasugrel 5 mg provides more predictable platelet inhibition compared with clopidogrel in the elderly, suggesting the possibility of reducing ischemic events without increasing bleeding. METHODS: In a multicenter, randomized, open-label, blinded end point trial, we compared a once-daily maintenance dose of prasugrel 5 mg with the standard clopidogrel 75 mg in patients >74 years of age with acute coronary syndrome undergoing percutaneous coronary intervention. The primary end point was the composite of mortality, myocardial infarction, disabling stroke, and rehospitalization for cardiovascular causes or bleeding within 1 year. The study was designed to demonstrate superiority of prasugrel 5 mg over clopidogrel 75 mg. RESULTS: Enrollment was interrupted, according to prespecified criteria, after a planned interim analysis, when 1443 patients (40% women; mean age, 80 years) had been enrolled with a median follow-up of 12 months, because of futility for efficacy. The primary end point occurred in 121 patients (17%) with prasugrel and 121 (16.6%) with clopidogrel (hazard ratio, 1.007; 95% confidence interval, 0.78-1.30; P=0.955). Definite/probable stent thrombosis rates were 0.7% with prasugrel versus 1.9% with clopidogrel (odds ratio, 0.36; 95% confidence interval, 0.13-1.00; P=0.06). Bleeding Academic Research Consortium types 2 and greater rates were 4.1% with prasugrel versus 2.7% with clopidogrel (odds ratio, 1.52; 95% confidence interval, 0.85-3.16; P=0.18). CONCLUSIONS: The present study in elderly patients with acute coronary syndromes showed no difference in the primary end point between reduced-dose prasugrel and standard-dose clopidogrel. However, the study should be interpreted in light of the premature termination of the trial. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01777503.

Electrocardiographic evolution in patients with hypertrophic cardiomyopathy who develop a left ventricular apical aneurysm.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) patients with apical aneurysm have a largely unfavourable clinical course, and are often unrecognised because echocardiography is limited in the assessment of the left ventricular (LV) apex. The aim of this study is the identification of electrocardiographic (ECG) abnormalities associated with the development of apical aneurysm in HCM patients. MATERIALS AND METHODS: Electrocardiographic features were assessed in 14 HCM patients who had a good-quality baseline ECG recorded before and after the diagnosis of apical aneurysm. RESULTS: During follow-up (8.8±7.5years), the following ECG changes were observed: increase in QRS-complex duration (87±12ms to 118±34ms, p=0.006), QRS-complex fragmentation, decrease in QRS-complex amplitude (SV1+RV5-6, from 41±18mm to 26±11mm, p=0.015), ST-segment elevation in V4-V6 (J-point in V5, from -0.9±1.3mm to +0.7±1.3, p=0.003), positivisation of negative T waves in V3-V6 (T-wave depth in V5, from -3.4±6.6 to +3.1±4.1, p=0.005). CONCLUSIONS: HCM patients who develop LV apical aneurysm exhibit distinctive ECG changes along with apical remodelling. Suggestive ECGs should lead the physician to study LV apex by nonstandard echocardiographic views, and perform MRI.

Intramyocardial calcification in apical hypertrophic cardiomyopathy assessed using multimodality imaging: a case series.

Apical hypertrophic cardiomyopathy (ApHCM) is an HCM variant, affecting frequently males in midlife. It is characterized by apical obliteration and persistent diastolic contraction, often resulting in microvascular ischaemia. We report five cases of ApHCM, with evidence of intramyocardial calcification on echocardiogram. On cardiac magnetic imaging (MRI), a hypointense component at early gadolinium enhancement (EGE) sequences, compatible with calcium, and a deep layer, with hyperintensity at late gadolinium enhancement (LGE) sequences, referable to fibrosis, suggest an endomyocardial fibrosis (EMF) diagnosis. EMF pathologic hallmark is endocardium and myocardium scarring, evolving to dystrophic calcification. It is found only in few ApHCM patients. Our series is the largest one described until now. Analysing patients' history, coexistent inflammatory triggers were evident in all of them, so their co-morbidities could represent a further cause of small vessel disease, in the context of ischaemic microvascular stress due to hypertrophy, leading to fibrosis and dystrophic calcification. This series could demonstrate the relation between apical fibrosis/calcification and microvascular ischaemia due to hypertrophy and inflammatory triggers.

Transcatheter Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: A Multicenter Propensity Score-Based Analysis.

Background: The prognostic impact of catheter ablation (CA) of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients has not yet been satisfactorily elucidated. Objectives: The aim of the study was to assess the impact of CA of AF on clinical outcomes in a large cohort of HCM patients. Methods: In this retrospective multicenter study, 555 HCM patients with AF were enrolled, 140 undergoing CA and 415 receiving medical therapy. 1:1 propensity score matching led to the inclusion of 226 patients (113 medical group, 113 intervention group) in the final analysis. The primary outcome was a composite of all-cause mortality, heart transplant and acute heart failure exacerbations. Secondary outcomes included AF recurrence and transition to permanent AF. Additionally, an inverse probability weighted (IPW) model was examined. Results: At propensity score matching analysis, after a median follow-up of 58.1 months, the primary endpoint occurred in 29 (25.7%) patients in intervention group vs 42 (37.2%) in medical group (P = 0.9). Thromboembolic strokes and major arrhythmic events in intervention vs medical group were 9.7% vs 7.1% (P = 0.144) and 4.4 vs 8.0% (P = 0.779), respectively. Fewer patients in intervention vs medical group experienced AF recurrences (63.7% vs 84.1%, P = 0.001) and transition to permanent AF pattern (20.4% vs 33.6%, P = 0.026). IPW analysis showed consistent results. Severe complications related to CA were uncommon (0.7%). Conclusions: After 5 years of follow-up, CA did not improve major adverse cardiac outcomes in a large cohort of patients with HCM and AF. Nevertheless, CA seems to facilitate the maintenance of sinus rhythm and slow the progression to permanent AF, without significant safety concerns.

[The importance of intensive lipid-lowering therapy after acute coronary syndrome: changing the paradigm to improve the achievement of targets]. / L'importanza di una terapia ipolipemizzante intensiva dopo sindrome coronarica acuta: cambiare il paradigma per migliorare il raggiungimento dei target.

BACKGROUND: Despite the availability of effective lipid-lowering drugs, only few high-risk patients attain their LDL cholesterol (LDL-C) guideline-recommended risk-based goal because of underprescription of combination therapy. We present an 18-month experience with variation of prescription protocols after publication of the 2019 ESC/EAS guidelines for the management of dyslipidemias. METHODS: Overall, 621 consecutive patients hospitalized for acute coronary syndrome at Mauriziano Hospital in Turin, Italy, between January 2020 and June 2021 were enrolled. Lipid-lowering therapy recommended at discharge was registered to evaluate how many patients received statin monotherapy, statin plus ezetimibe combination or triple therapy with high-intensity statin plus ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i). At 6-month follow-up, the reduction in LDL-C, adverse events, compliance and cardiovascular recurrences was analyzed. RESULTS: Of 621 patients enrolled, 7 died during hospitalization. During the entire study period, 33% of patients received statin monotherapy, 50% were discharged on statin-ezetimibe combination, and PCSK9i (evolocumab) was prescribed to 17% of patients. Between April 2020 and June 2021, when new recommendations were introduced into clinical practice, 20% of patients received evolocumab, 56% combination therapy and only 24% were discharged on statin monotherapy. At the beginning of observation, evolocumab was prescribed to 3% of patients hospitalized for acute coronary syndrome, while at the end of the study period 27% of patients were discharged on PCSK9i, with an increase of the prescription rate by 759%; in the same period, prescription of statin monotherapy decreased by 75%. At 6-month follow-up, LDL-C reduction was 77% in patients treated with PCSK9i vs 48% in patients taking statin-ezetimibe combination therapy (p<0.001). All patients on evolocumab reached the guideline-directed goals and a low rate of adverse events was reported, mainly represented by local injection site reactions. Six patients experienced acute coronary syndrome recurrence; only one of them was treated with evolocumab. CONCLUSION: Prescription of intensive lipid-lowering therapy after acute coronary syndrome, eventually with introduction of PCSK9i during hospitalization or at discharge, leads to attainment of guideline-recommended goals for all patients, with a low incidence of adverse events and optimal compliance.

Impact of hemoglobin levels at admission on outcomes among elderly patients with acute coronary syndrome treated with low-dose Prasugrel or clopidogrel: A sub-study of the ELDERLY ACS 2 trial.

Hemoglobin (Hb) levels have emerged as a useful tool for risk stratification and the prediction of outcome after myocardial infarction. We aimed at evaluating the prognostic impact of this parameter among patients in advanced age, where the larger prevalence of anemia and the higher rate of comorbidities could directly impact on the cardiovascular risk. METHODS: All the patients in the ELDERLY-2 trial, were included in this analysis and stratified according to the values of hemoglobin at admission. The primary endpoint of this study was cardiovascular mortality within one year. The secondary endpoints were all-cause mortality, MI, Bleeding Academic Research Consortium (BARC) type 2-3 or 5 bleeding, any stroke, re-hospitalization for cardiovascular event or stent thrombosis (probable or definite) within 12 months after index admission. RESULTS: We included in our analysis 1364 patients, divided in quartiles of Hb values (<12.2; 12.2-13.39; 13.44-14.49; ≥ 4.5 g/dl). At a mean follow- up of 330.4 ± 99.9 days cardiovascular mortality was increased in patients with lower Hb (HR[95%CI] = 0.76 [0.59-0.97], p = 0.03). Results were no more significant after correction for baseline differences (adjusted HR[95%CI] = 1.22 [0.41-3.6], p = 0.16). Similar results were observed for overall mortality. At subgroup analysis, (according to Hb median values) a significant interaction was observed only with the type of antiplatelet therapy, but not with major high-risk subsets of patients. CONCLUSIONS: Among elderly patients with acute coronary syndrome managed invasively, lower hemoglobin at admission is associated with higher cardiovascular and all-cause mortality and major ischemic events, mainly explained by the higher risk profile.

Late gadolinium enhancement on cardiac magnetic resonance and phenotypic expression in hypertrophic cardiomyopathy.

BACKGROUND: Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) can identify areas of myocardial fibrosis in vivo in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to examine the association between clinical-morphological variables, risk factor for sudden death, and LGE findings in a consecutive, unselected population of HCM patients. METHODS: From January 2005 to August 2009, 124 HCM patients (53 ± 17 years, 86 men) were prospectively evaluated with CMR examination, assessing left ventricular (LV) hypertrophy, function, and LGE. RESULTS: In univariate analysis, patients were divided into tertiles according to the number of segments positive for LGE (first tertile, 0.3 ± 0.4; second tertile, 2.2 ± 0.4; third tertile, 5.2 ± 1.9 segments). Male gender (P = .05), maximum LV wall thickness (P = .002), nonsustained ventricular tachycardia (P = .001), ejection fraction <50% (P = .02), LV mass (P = .02), left atrium dilation (P = .04), perfusion defects (P ≤ .001), and telesystolic volume (P = .04) were all positively related with the number of segments of LGE. In multivariable analysis, male gender (P = .007), maximum LV wall thickness (P = .006), LV mass (P = .031), and perfusion alterations (P = .017) were independent predictors of LGE extent. CONCLUSIONS: Our study shows an independent association, even at multivariate analysis, between the entity of LGE and maximum LV wall thickness, mass, and perfusion defects in patients with HCM. Whether the presence and the extent of LGE translates into clinical events later on awaits further long-term follow-up studies.

Syncope and risk of sudden death in hypertrophic cardiomyopathy.

BACKGROUND: The prognostic significance of syncope has not been investigated systematically in hypertrophic cardiomyopathy, and treatment strategies have been based largely on intuition and experience. METHODS AND RESULTS: We assessed the relationship between syncope and sudden death in 1511 consecutive patients with hypertrophic cardiomyopathy. Unexplained (n=153) or neurally mediated (n=52) syncope occurred in 205 patients (14%). Over a 5.6+/-5.2-year follow-up, 74 patients died suddenly. Relative risk of sudden death was 1.78 (95% confidence interval 0.88 to 3.51, P=0.08) in patients with unexplained syncope and 0.91 (95% confidence interval 0.00 to 3.83, P=1.0) in those with neurally mediated syncope compared with patients without syncope. In multivariable analysis, the temporal proximity of unexplained syncope to initial patient evaluation was independently associated with risk of sudden death (P=0.006). Patients with unexplained syncope within 6 months before the initial evaluation showed a 5-fold increase in risk compared with patients without syncope (adjusted hazard ratio 4.89, 95% confidence interval 2.19 to 10.94), a relationship that was maintained throughout all age groups (<18, 18 to 39, and > or =40 years). Older patients (> or =40 years of age) with remote episodes of syncope (>5 years before initial evaluation) did not show an increased risk of sudden death (adjusted hazard ratio 0.38, 95% confidence interval 0.05 to 2.74). CONCLUSIONS: In the present large cohort of patients with hypertrophic cardiomyopathy, unexplained syncope was a risk factor for sudden death. Patients with syncopal events that occurred in close temporal proximity to the initial evaluation showed a substantially higher risk of sudden death than patients without syncope. Older patients with remote syncopal events did not show an increased risk.

Impact of diabetes on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: insights from the ELDERLY ACS 2 trial.

BACKGROUND: Despite recent improvements in percutaneous coronary revascularization and antithrombotic therapies for the treatment of acute coronary syndromes, the outcome is still unsatisfactory in high-risk patients, such as the elderly and patients with diabetes. The aim of the current study was to investigate the prognostic impact of diabetes on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study carried out at 32 centers in Italy. METHODS: Our population is represented by 1443 patients included in the Elderly-ACS 2 trial. Diabetes was defined as known history of diabetes at admission. The primary endpoint of this analysis was cardiovascular mortality, while secondary endpoints were all-cause death, recurrent myocardial infarction, Bleeding Academic Research Consortium type 2 or 3 bleeding, and rehospitalization for cardiovascular event or stent thrombosis within 12 months after index admission. RESULTS: Diabetes was present in 419 (29%) out of 1443 patients. Diabetic status was significantly associated with major cardiovascular risk factors and history of previous coronary disease, presentation with non-ST segment elevation myocardial infarction (P = 0.01) more extensive coronary disease (P = 0.02), more advanced Killip class at presentation (P = 0.003), use at admission of statins (P = 0.004) and diuretics at discharge (P < 0.001). Median follow-up was 367 days (interquartile range: 337-378 days). Diabetic status was associated with an absolute increase in the rate of cardiovascular mortality as compared with patients without diabetes [5.5 vs. 3.3%, hazard ratio (HR) 1.7 (0.99-2.8), P = 0.054], particularly among those treated with clopidogrel [HR (95% confidence interval (CI)) = 1.89 (0.93-3.87), P = 0.08]. However, this difference disappeared after correction for baseline differences [Adjusted HR (95% CI) 1.1(0.4-2.9), P = 0.86]. Similar findings were observed for other secondary endpoints, except for bleeding complications, significantly more frequent in diabetic patients [HR (95% CI) 2.02 (1.14-3.6), P = 0.02; adjusted HR (95% CI) = 2.1 (1.01-4.3), P = 0.05]. No significant interaction was observed between type of dual antiplatelet therapy, diabetic status and outcome. CONCLUSION: Among elderly patients with acute coronary syndromes, diabetic status was associated with higher rates of comorbidities, more severe cardiovascular risk profile and major bleeding complications fully accounting for the absolute increase in mortality. In fact, diabetes mellitus did not emerge as an independent predictor of survival in advanced age.

Relation of QRS duration to mortality in a community-based cohort with hypertrophic cardiomyopathy.

A prolonged QRS duration on the standard electrocardiogram is associated with an increased risk of cardiovascular death in cardiomyopathies of different origin. However, the relation between QRS duration and prognosis in hypertrophic cardiomyopathy (HC) remains undefined. We assessed the relation between QRS duration and cardiovascular death in 241 consecutive patients with HC. The study cohort was divided into 2 groups according to QRS duration: <120 and > or =120 ms. Of the 241 patients, 191 (79%) had a QRS duration <120 ms and 50 (21%) a QRS duration > or =120 ms. During a mean follow-up of 7.9 +/- 5.1 years, 35 patients died of cardiovascular causes related to HC. Of these 35 patients, 13 (6%) had a QRS duration <120 ms and 22 (43%) had a QRS duration > or =120 ms (p <0.01). Risk of cardiovascular death was significantly higher in patients with a QRS duration > or =120 ms than in those with a QRS duration <120 ms (relative risk 5.2, p <0.0001). At 8-year follow-up, cumulative risks of HC-related death were 7.1% in patients with a QRS duration <120 ms and 55% in those with a QRS duration > or =120 ms. Multivariate analysis confirmed that a QRS duration > or =120 ms was independently associated with an increased risk of cardiovascular death (hazard ratio 3.2, p = 0.007). New York Heart Association functional class III/IV was the only other clinical variable significantly and independently associated with an increased risk of cardiovascular death. In conclusion, in patients with HC, QRS duration on standard electrocardiogram is directly related to cardiovascular mortality, and a QRS duration > or =120 ms is a strong and independent predictor of prognosis.

Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy.

OBJECTIVES: We sought to assess the occurrence and clinical significance of stroke and peripheral arterial embolizations at non-central nervous system sites in a large, community-based cohort with hypertrophic cardiomyopathy (HCM). BACKGROUND: Such vascular events are insufficiently appreciated complications of HCM for which there is limited information on occurrence, clinical profile and determinants. METHODS: We assessed the clinical features of patients with stroke and other peripheral vascular events in a consecutive group of patients with HCM from four regional cohorts not subject to significant tertiary referral bias. RESULTS: Of the 900 patients, 51 (6%) patients experienced stroke or other vascular events over 7 +/- 7 years, including 44 patients with stroke; 21 (41%) of these 51 patients died or were permanently disabled. The overall incidence was 0.8%/year and 1.9% for patients >60 years old. Age at first event ranged from 29 to 86 years (mean 61 +/- 14 years). Most (n = 37; 72%) events occurred in those >50 years, although 14 (28%) younger patients (< or = 50 years) also had events. Multivariate analysis showed stroke and other peripheral vascular events to be independently associated with congestive symptoms and advanced age, as well as with atrial fibrillation (in 45 [88%] of 51 patients), at the initial evaluation. The cumulative incidence of these events among patients with atrial fibrillation was significantly higher in non-anticoagulated patients as compared with patients receiving warfarin (31% vs. 18%; p < 0.05). CONCLUSIONS: Stroke and peripheral embolizations showed a 6% prevalence rate and an incidence of 0.8%/year in a large, unselected HCM group. These profound complications of HCM, which may lead to disability and death, were substantially more common in the elderly, occurred almost exclusively in patients with paroxysmal or chronic atrial fibrillation and appeared to be reduced in frequency by anticoagulation.

[Primary angioplasty in a patient with the May-Hegglin anomaly, a rare heredity thrombocytopenia. A case report and review of the literature]. / Infarto miocardico acuto trattato con angioplastica primaria in una rara forma di piastrinopenia ereditaria: anomalia di May-Hegglin. Caso clinico e revisione della letteratura.

The May-Hegglin anomaly (MHA) is a rare autosomal dominant platelet disorder characterized by thrombocytopenia, giant platelets and leukocyte inclusion bodies. Many patients affected by the MHA have a marked hemorrhagic tendency, a well known contraindication to thrombolytic and anticoagulant therapies. We report a case of a 56-year-old woman with the MHA, referred to our department with an evolving acute ST-elevation myocardial infarction. The patient underwent urgent coronary angiography revealing the acute occlusion of the distal left anterior descending coronary artery, treated with a thrombus aspiration system. In view of the absence of residual stenosis, no balloon dilation and stent deployment were performed. No antiaggregant and anticoagulant therapy was administered. The procedure has been successful, the hospital course was uneventful and the patient was discharged 5 days later. At a 30-day follow-up the patient was asymptomatic and in a good hemodynamic state. To the best of our knowledge, this report is the first description of managing a myocardial infarction in a patient affected by the MHA in the reperfusion era.

[Heart rupture in acute myocardial infarction: multicenter observational study of the coronary unit of Piedmont]. / Rottura di cuore nell'infarto miocardico acuto: studio multicentrico osservazionale delle unità coronariche piemontesi.

BACKGROUND: The aim of this study was to prospectively evaluate the incidence of cardiac rupture during myocardial infarction (MI) as well as the predictive value of the main cardiac rupture risk factors. METHODS: The study was carried out in 17 coronary care units (CCU) between January and December 1999 in the Piedmont region (Italy). RESULTS: The incidence of cardiac rupture was 1.4% of the total number of MI (n = 3041). Data from 13 out of 17 CCU showed the following causes of death during MI: 66% heart failure, 16% cardiac rupture, 7% arrhythmias, 11% others. Twenty-seven percent out of 44 cardiac ruptures had prior angina, 9% prior MI; 24% of patients were diabetic; 38% had anterior wall MI; 62% infero-postero-lateral MI; 86% showed ST-segment elevation, and 79.5% developed Q waves. Thrombolysis was administered in 39% of cases. Forty-three percent cardiac ruptures occurred within 24 hours. Electromechanical dissociation was present in 73% of cases, syncope and hypotension in 43%, bradycardia in 30%. An echocardiogram was performed in 89% of cases in the suspicion of cardiac rupture but only 45% showed severe pericardial effusion. One patient was referred to surgery but he died in the postoperative period. Autoptical diagnosis was made in 32% of cases. All patients died. The analysis of some qualitative variables (gender, thrombolysis, MI localization, ST-segment/non-ST-segment elevation) in 8 out of 17 CCU, between the cardiac rupture group (n = 22) and the MI group (n = 1330) showed a significant result only for the female gender. CONCLUSIONS: Cardiac rupture is the second cause of death during MI after heart failure; there is a higher incidence of cardiac rupture in infero-postero-lateral MI, after the first 24 hours particularly in the female gender; there is a low global incidence (1.4%).

[Initial experience in the management of myocardial infarction with primary angioplasty: results of the activity in two hospitals of the Turin area without on-site cardiac surgery]. / Iniziale esperienza organizzativa nel trattamento con angioplastica primaria dell'infarto miocardico acuto in due ospedali torinesi territoriali non dotati di cardiochirurgia: primi tre anni di attività.

BACKGROUND: Reperfusion therapy of ST-elevation myocardial infarction (STEMI) with primary coronary angioplasty (PTCA) is becoming an accepted therapeutical strategy because of a lower incidence of reinfarction, of hemorrhagic stroke and for a greater reduction of the infarct size in comparison to thrombolytic therapy. In this study we evaluated the feasibility and the effectiveness of such a strategy in two hospitals without on-site heart surgery but with a high volume of admission for acute coronary syndrome and a high caseload of elective interventional procedures. METHODS: Since January 2001 we started a program of primary PTCA for all STEMI patients presenting within 12 hours of symptom onset. An interventional team (physician, nurse and technician) were on call in a 24/7/365 fashion. Aspirin, heparin and abciximab were administered in the emergency room to all patients. Immediately after the procedure patients were given clopidogrel. RESULTS: Up to December 2003, 464 patients (mean age 63 +/- 12 years, 19.8% female) underwent primary PTCA. The symptom-emergency room interval was 3 +/- 3.9 hours, while the door-to-balloon time was 52.5 +/- 39.4 min. A TIMI 0-1 flow in the infarct-related artery was present in 55.8% of patients. Seventy patients (15.1%) presented with shock. In 430 patients (92.7%) a TIMI 3 flow was restored followed by a reduction in ST-segment elevation > 50% in 356 patients (76.7%). Total in-hospital mortality was 4.9% (23 out of 464 patients). The mortality of patients with shock was 31.4% (22 out of 70 patients). Two patients (0.4%) underwent emergency bypass. Four patients (0.8%) were electively referred to surgery prior to discharge in order to complete revascularization, which could not be obtained with further PTCA. The rate of major hemorrhagic complications was 0.8%. CONCLUSIONS: Primary PTCA for STEMI is a reperfusion strategy feasible and effective even in hospitals without on-site heart surgery, provided that a high volume of routine and emergency interventional procedures is maintained and when such a strategy is timely performed according to international guidelines.

Risk of sudden death and outcome in patients with hypertrophic cardiomyopathy with benign presentation and without risk factors.

Patients with hypertrophic cardiomyopathy (HC) are reported to have a mortality rate of about 1.0% per year, and those patients without sudden death risk factors and with no or mild symptoms are generally considered to have a benign clinical presentation. However, the risk of sudden death and the outcome in this latter subgroup have not been investigated systematically and remain unresolved. We assessed the risk of sudden death and outcome in 653 consecutive patients with HC without risk factors and with no or mild symptoms. Over a median follow-up of 5.3 years, 35 patients (5.4%) died of HC-related causes. Mean age at death was 46 ± 20 years in patients who died suddenly and 66 ± 15 and 72 ± 9 years, respectively, in patients who died of heart failure or stroke. Event rate was 0.6% per year for sudden death, 0.2% per year for heart failure death, and 0.1% per year for stroke-related death. Sudden death risk was independently and inversely related to age, and risk of heart failure or stroke death was directly related to age (p = 0.020). At 10 years after the initial evaluation, sudden death risk was 5.9%, with sudden death rate being the lowest (0.3% per year) in patients with normal left atrial dimension (≤40 mm). In conclusion, in patients with HC without conventional risk factors and with no or mild symptoms, the risk of sudden death was not negligible, with an event rate of 0.6% per year. Heart failure and stroke-related death were less common and largely confined to older patients. These results underscore the need for a more accurate assessment of the sudden death risk in patients with HC.

Care of acute myocardial infarction in the coronary care units of Piedmont in 2007: results from the 'PRIMA_sweet' region-wide survey.

BACKGROUND: The treatment of acute myocardial infarction (AMI), both with ST-segment elevation [ST-elevation myocardial infarction (STEMI)] and non-ST-segment elevation [non-ST-elevation myocardial infarction (NSTEMI)], is evolving in Piedmont, with an increase in interventional procedures and hub-and-spoke networks. This new region-wide survey provides updated assessment of the management of STEMI and unprecedented data on NSTEMI. METHODS: In 30 coronary care units in Piedmont, all patients with AMI symptoms of duration less than 48 h, between January and March 2007, were included. RESULTS: Of 921 patients, 447 had STEMI and 474 NSTEMI. Diabetes was present in 35% and chronic kidney disease in 38%. Hospital mortality was 4.7% [95% confidence interval (CI) 3.3-6.1]: age 75 years or older, Killip class higher than 1 and known diabetes or abnormal blood glucose on admission were multivariate predictors. Thrombolysis and primary percutaneous transluminal coronary angioplasty (pPTCA) were performed in 17.6 and 53.1% of 391 patients, respectively, with STEMI of 12 h or less, and 29.3% had no reperfusion therapy, notably 52% of patients aged 75 years or older and 51% of those reaching non-24/24 h interventional centres. Mortality after pPTCA was 2.5% and onsite door-to-balloon time was less than 90 min in 67.5%. Overall mortality after STEMI was 5.4% (95% CI 3.2-7.6). In NSTEMI, use of antithrombotic treatments was extensive, but invasive treatment within 72 h was limited to 8% of patients in centres without interventional facilities and independent of patient's risk profile. Mortality after NSTEMI was 4.0% (95% CI 2.2-5.8) and was predicted by both the Global Registry of Acute Coronary Events risk score and diabetes. CONCLUSION: There is room for improvement in the treatment of AMI in our region, with more extensive use of reperfusion therapy in STEMI, especially in the elderly, and early revascularization and optimal medical treatment in higher-risk NSTEMI.

Primary angioplasty and routine utilization of thrombus aspiration devices: feasibility and results in a consecutive series of 486 patients.

BACKGROUND: Primary percutaneous transluminal coronary angioplasty (PTCA) is the treatment of choice for acute ST-segment elevation myocardial infarction (STEMI) in high-volume centres with experienced operators, but is often limited by a suboptimal microvascular perfusion due to distal embolization and impaired myocardial perfusion. The present study investigates whether routine use of thrombus aspiration (TA) devices is feasible in daily practice, along with its safety and effectiveness. METHODS: This study is based on a series of 486 consecutive STEMI patients treated at our single institution by the same three operators (from 2001 to 2005). They underwent primary PTCA with or without TA according to these angiographic features: infarct related artery (IRA) diameter>or=3 mm; thrombotic occlusion or angiographic evidence of thrombus; absence of severe proximal tortuosity or calcification. We evaluate the efficacy of TA in terms of procedural success, coronary thrombolysis in myocardial infarction (TIMI) flow, myocardial blush grade (MBG), resolution>or=50% of ST segment elevation, and clinical events during hospital stay and at 6-month follow-up. RESULTS: A total of 486 primary PTCAs were performed, 217 (44.6%) with TA as a first device using RESCUE (n=65), EXPORT (n=140) and DIVER-CE (n=12) catheters. In 141 (65%) cases, macroscopic material was aspirated. The patients submitted to TA were more often males (84.7% versus 71.7%, P<0.05) and younger (age: 61.02+/-11.91 versus 64.47+/-10.59 years, P<0.01) than patients treated with traditional PTCA and the IRA was more frequently occluded at angiography (basal TIMI 0: 70.5% versus 47.9%). Application of the TA did not increase the complexity of the procedure (door-to-balloon times, minutes of fluoroscopy and amount of dye). TA alone was effective to restore TIMI 3 flow in 187 cases (86.2%) as a first device and in three other cases (1.4%) after predilatation with balloon. Direct stenting without predilatation was possible in 144 cases (66.4%) after TA. TA was not effective in 27 cases (12.4%) and this subgroup had both angiographic and clinical unfavourable results in comparison with the effective TA group (final TIMI 1 in 11.1% versus 0.5%, P<0.015; final MBG 1 in 55.5% versus 9.5%, P<0.001; lack of ST segment resolution>or=50% in 44.4% versus 7.9%, P<0.001; in-hospital mortality 14.8% versus 2.6%, P<0.05 and mortality at 6 months 18.5% versus 3.1%, P<0.05). In the whole TA population, final TIMI 3 flow was achieved in 203 cases (93.5%), final MBG 3 in 145 cases (66.8%) and ST segment resolution>or=50% in 185 cases (85.2%), in-hospital mortality was 4.1% and cumulative mortality at 6-month follow-up was 5.5%. CONCLUSIONS: In our case series, 486 consecutive unselected patients with STEMI were treated in a primary PTCA high-volume centre using TA devices. Our study demonstrates that, in STEMI patients treated with primary PTCA, a routine strategy with TA before angioplasty guided by angiographic selection criteria is feasible in almost 50% of cases, is safe and effective, does not increase procedural time and offers good results in terms of tissue perfusion, both epicardial (TIMI flow) and myocardial (MBG, ST regression). When successfully performed, TA identifies a population with favourable in-hospital and 6-month outcome.