Effect of Escitalopram on All-Cause Mortality and Hospitalization in Patients With Heart Failure and Depression: The MOOD-HF Randomized Clinical Trial.

IMPORTANCE: Depression is frequent in patients with heart failure and is associated with adverse clinical outcomes. Long-term efficacy and safety of selective serotonin reuptake inhibitors in these patients are unknown. OBJECTIVE: To determine whether 24 months of treatment with escitalopram improves mortality, morbidity, and mood in patients with chronic systolic heart failure and depression. DESIGN, SETTING, AND PARTICIPANTS: The Effects of Selective Serotonin Re-Uptake Inhibition on Morbidity, Mortality, and Mood in Depressed Heart Failure Patients (MOOD-HF) study was a double-blind, placebo-controlled randomized clinical trial conducted at 16 tertiary medical centers in Germany. Between March 2009 and February 2014, patients at outpatient clinics with New York Heart Association class II-IV heart failure and reduced left ventricular ejection fraction (<45%) were screened for depression using the 9-item Patient Health Questionnaire. Patients with suspected depression were then invited to undergo a Structured Clinical Interview based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) to establish the diagnosis. INTERVENTIONS: Patients were randomized 1:1 to receive escitalopram (10-20 mg) or matching placebo in addition to optimal heart failure therapy. Study duration was 24 months. MAIN OUTCOMES AND MEASURES: The composite primary outcome was time to all-cause death or hospitalization. Prespecified secondary outcomes included safety and depression severity at 12 weeks of treatment (including the titration period), which were determined using the 10-item Montgomery-Åsberg Depression Rating Scale (total possible score, 0 to 60; higher scores indicate more severe depression). RESULTS: A total of 372 patients (mean age, 62 years; 24% female) were randomized and had taken at least 1 dose of study medication when the data and safety monitoring committee recommended the trial be stopped early. During a median participation time of 18.4 months (n = 185) for the escitalopram group and 18.7 months (n = 187) for the placebo group, the primary outcome of death or hospitalization occurred in 116 (63%) patients and 119 (64%) patients, respectively (hazard ratio, 0.99 [95% CI, 0.76 to 1.27]; P = .92). The mean Montgomery-Åsberg Depression Rating Scale sum score changed from 20.2 at baseline to 11.2 at 12 weeks in the escitalopram group and from 21.4 to 12.5 in the placebo group (between-group difference, -0.9 [95% CI,-2.6 to 0.7]; P = .26). Safety parameters were comparable between groups. CONCLUSIONS AND RELEVANCE: In patients with chronic heart failure with reduced ejection fraction and depression, 18 months of treatment with escitalopram compared with placebo did not significantly reduce all-cause mortality or hospitalization, and there was no significant improvement in depression. These findings do not support the use of escitalopram in patients with chronic systolic heart failure and depression. TRIAL REGISTRATION: isrctn.com Identifier: ISRCTN33128015.

OMEGA, a randomized, placebo-controlled trial to test the effect of highly purified omega-3 fatty acids on top of modern guideline-adjusted therapy after myocardial infarction.

BACKGROUND: There is no randomized, double-blind trial testing the prognostic effect of highly purified omega-3 fatty acids in addition to current guideline-adjusted treatment of acute myocardial infarction. METHODS AND RESULTS: OMEGA is a randomized, placebo-controlled, double-blind, multicenter trial testing the effects of omega-3-acid ethyl esters-90 (1 g/d for 1 year) on the rate of sudden cardiac death in survivors of acute myocardial infarction, if given in addition to current guideline-adjusted treatment. Secondary end points were total mortality and nonfatal clinical events. Patients (n=3851; female, 25.6%; mean age, 64.0 years) were randomized in 104 German centers 3 to 14 days after acute myocardial infarction from October 2003 until June 2007. Acute coronary angiography was performed in 93.8% and acute percutaneous coronary intervention in 77.8% of all patients. During a follow-up of 365 days, the event rates were (omega and control groups) as follows: sudden cardiac death, 1.5% and 1.5% (P=0.84); total mortality, 4.6% and 3.7% (P=0.18); major adverse cerebrovascular and cardiovascular events, 10.4% and 8.8% (P=0.1); and revascularization in survivors, 27.6% and 29.1% (P=0.34). CONCLUSIONS: Guideline-adjusted treatment of acute myocardial infarction results in a low rate of sudden cardiac death and other clinical events within 1 year of follow-up, which could not be shown to be further reduced by the application of omega-3 fatty acids. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00251134.

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.

Antibiotic therapy after acute myocardial infarction: a prospective randomized study.

BACKGROUND: Infection with Chlamydia pneumoniae is suspected to contribute to the pathogenesis of human atherosclerosis. We investigated whether treatment with the macrolide antibiotic roxithromycin would reduce mortality or morbidity in patients with an acute myocardial infarction. METHODS AND RESULTS: Eight hundred seventy-two patients with an acute myocardial infarction (AMI) were randomly assigned to receive double-blind treatment with either 300 mg roxithromycin or placebo daily for 6 weeks. Primary end point was total mortality during 12-month follow-up. Four hundred thirty-three patients were treated with roxithromycin and 439 with placebo. With the exception of a higher proportion of patients suffering an anterior wall AMI (48.1% in the roxithromycin group versus 40.2% in the placebo group; P=0.027) and a lower prevalence of chronic obstructive pulmonary disease in the roxithromycin group (3.5% versus 6.9%, P=0.028), baseline characteristics, reperfusion therapy, and medical treatment were well balanced between the two groups. More patients in the roxithromycin group interrupted their study medication before completion of at least 4 weeks of treatment (78 of 433 [18%] versus 48 of 439 [11%]; P=0.003; odds ratio, 1.8; 95% CI, 1.2 to 2.6). Follow-up at 12 months was achieved in 868 of 872 (99.5%) patients. Total mortality at 12 months was 6.5% (28 of 431) in the roxithromycin group compared with 6.0% (26 of 437) in the placebo group (odds ratio, 1.1; 95% CI, 0.6 to 1.9; P=0.739). There were also no differences in the secondary combined end points at 12 months. CONCLUSIONS: Treatment of AMI patients with roxithromycin did not reduce event rates during 12 months of follow-up. Therefore, our findings do not support the routine use of antibiotic treatment with a macrolide in patients with AMI.

Publication performance of women compared to men in German cardiology.

BACKGROUND: Abstract presentations at scientific congresses are a preparation for publication in peer reviewed journals. The present study aimed to investigate the prediction of abstract acceptance of peer reviewed publications focusing on the difference between male and female first authors. METHODS: We evaluated 8411 abstracts submitted to the German Cardiac Society by 2090 females and 6321 male scientists. Abstract grading (3 to 9 reviewers, blinded on a 5-point scale) separated those accepted and rejected followed by a bibliometric analysis of Medline publications from 2006 to 2012. RESULTS: While rating of abstracts was not different between males and females (p=0.475), publication rate of females was lower compared to males (17.5% vs 24.4 ≥%, p<0.001). Female authors achieved a higher impact factor in their publications (5.1 ± 0.2 vs 4.4 ± 0.1, p=0.0003) and were more often listed on papers in highly ranked journals (impact factor ≥ 5) than males. Although, more accepted abstracts than rejected ones were published in high rank journals, a considerable number of papers were generated from rejected abstracts (22%). CONCLUSIONS: Female cardiologists had a better publication success than males concerning high rank peer reviewed publications. Acceptance in blinded abstract evaluation often detects work published later, while rejected contributions still might represent high quality work suitable for publication in peer reviewed journals.

[Predictive value of congress abstracts for later publication: Analysis of the the congresses 2006-2010 of the German Cardiac Society]. / Prädiktiver Wert der Evaluation von Kongressabstracts für die Publikationshäufigkeit und -qualität: Analyse der Jahreskongresse der Deutschen Gesellschaft für Kardiologie.

AIMS: The present study investigates whether scientific abstracts, which were accepted for presentation at the annual meeting of the German Cardiac Society (DGK) will be published more frequently and with higher ranking than rejected abstracts. Additionally, we analyzed whether the current peer review process of the congress abstracts is able to identify research of high quality. METHODS: All abstracts submitted for the DGK meetings between 2006 and 2010 were anonymized and graded by 5-9 reviewers. Based on these ratings, abstracts were accepted or rejected. A Medline search with name of the first author, key words and content of all abstracts was conducted to identify publications following the congress abstracts. In case of identification of a publication, the impact factor (IF) of the journal was assessed. RESULTS: 5535 (66 %) of 8411 submitted abstracts were accepted for presentation (basic reseach: 2497; clinical study: 5914). A total of 23 % of all abstracts were published (IF 3.6). The average time to publication was 0.7 ±â€…1.2 years, while 35 % of all published studies achieved publication in the year of congress. The publication rate was 26 % for accepted abstracts (IF 3.8) and 17 % (2.4) for rejected abstracts. Basic research achieved higher publication rates than clinical studies (26 % vs. 21 %) and had a higher average impact factor (IF 5.1 vs. 3). CONCLUSIONS: The present study shows that abstracts, which were accepted for presentation achieved a publication more frequently and in higher-ranked journals than rejected abstracts.

Different treatments and outcomes of consecutive patients with non-ST-elevation myocardial infarction depending on initial electrocardiographic changes (results of the Acute Coronary Syndromes [ACOS] Registry).

Of 6,302 consecutive patients with acute non-ST-elevation myocardial infarction, 42.8% presented with ST depression, 31.9% showed no significant electrocardiographic changes, and 25.3% presented with T inversion. In comparison with patients with T inversion or no significant electrocardiographic changes, patients with ST depression more often had 3-vessel coronary disease, received less acute therapy despite a strong benefit in a subgroup analysis, and had a worse clinical outcome even after adjustment in a multivariate analysis. Patients with T inversion received a high rate of acute therapy and had a better outcome than did patients without significant electrocardiographic changes and patients with ST depression.

Gender differences in acute myocardial infarction in the era of reperfusion (the MITRA registry).

There is conflicting information about gender differences in presentation, treatment, and outcome after acute ST elevation myocardial infarction (STEMI) in the era of thrombolytic therapy and primary percutaneous coronary intervention. From June 1994 to January 1997, we enrolled 6,067 consecutive patients with STEMI admitted to 54 hospitals in southwest Germany in the Maximal Individual TheRapy of Acute myocardial infarction (MITRA), a community-based registry. Women were 9 years older than men, more often had hypertension, diabetes mellitus, and congestive heart failure, and had a history of previous myocardial infarction less often. Women had a longer prehospital delay (45 minutes), had anterior wall infarction more often (odds ratio [OR] 1.21; 95% confidence interval [CI] 1.08 to 1.36), and received reperfusion therapy less often (OR 0.83; 95% CI 0.74 to 0.94). The percentage of patients who were eligible for thrombolysis and received no reperfusion was higher in women (OR 1.7; 95% CI 1.56 to 1.89). Women had recurrent angina (OR 1.45; 95% CI 1.23 to 1.71) and congestive heart failure (OR 1.26; 95% CI 1.01 to 1.56) more often. There was a trend toward a higher hospital mortality in women (age-adjusted OR 1.16, 95% CI 0.99 to 1.35; multivariate OR 1.21, 95% CI 0.96 to 1.51), but there was no gender difference in long-term mortality after multivariate analysis (age-adjusted OR 0.95, 95% CI 0.78 to 1.15; multivariate OR 0.93, 95% CI 0.72 to 1.19). Thus, women with STEMI receive reperfusion therapy less often than men. They experience recurrent angina and congestive heart failure more often during their hospital stay. The age-adjusted long-term mortality is not different between men and women, but there is a trend for a higher short-term mortality in women.

Usefulness of heart rate to predict one-year mortality in patients with atrial fibrillation and acute myocardial infarction (from the OMEGA trial).

In the setting of acute myocardial infarction and sinus rhythm, the heart rate (HR) has been demonstrated to correlate closely with mortality. In patients presenting with acute myocardial infarction and atrial fibrillation (AF) on admission, however, the prognostic relevance of the HR has not yet been systematically addressed. A post hoc subgroup analysis of the data from the OMEGA trial was conducted to analyze whether the admission HR determines the 1-year mortality in patients presenting with AF in the setting of acute myocardial infarction. Of 3,851 patients enrolled in the OMEGA study, 211 (6%) presented with AF on admission. This subgroup was dichotomized according to the admission HR (cutoff 95 beats/min). Multiple regression analysis revealed that an admission HR of ≥95 beats/min independently determined the 1-year mortality in patients with AF (odds ratio 4.69, 95% confidence interval 1.47 to 15.01; p = 0.01). In conclusion, this is the first study demonstrating that a high HR (≥95 beats/min) on admission in patients with AF and acute myocardial infarction is associated with an almost fivefold mortality risk.

Predictors of 1-year mortality in patients with contemporary guideline-adherent therapy after acute myocardial infarction: results from the OMEGA study.

BACKGROUND: Predictors of long-term mortality after discharge after acute myocardial infarction (AMI) are well characterized. However, these established risk factors are based on data almost exclusively derived from older studies without consistent use of revascularization therapy and adjunctive therapy with statins, platelet inhibitors, beta-blockers and ACE inhibitors/ARBs. We therefore sought to investigate predictors of 1-year mortality in survivors of AMI treated with contemporary guideline-adherent therapy. METHODS AND RESULTS: We performed a retrospective analysis of 3,782 patients surviving acute ST-elevation and non ST-elevation myocardial infarction who were enrolled in the prospective, randomized, double-blind, controlled OMEGA trial with 104 German centers. The primary objective of the OMEGA study was to determine the effect of highly purified omega-3 fatty acid ethyl esters-90 on the rate of sudden cardiac death in patients surviving AMI and receiving current guideline-adherent treatment within the 1-year of follow-up. 80.8 % of the patients received early revascularization therapy. At discharge, 94.2 % of the patients received beta-blocker, 90.4 % ACE inhibitor/angiotensin receptor blocker, 94.3 % statin, 95.4 % aspirin and 88.4 % clopidogrel. During the 1-year follow-up 139 patients (3.7 %) died. Multivariate logistic regression analysis revealed the following independent predictors of 1-year mortality in decreasing order of importance: ejection fraction <45 % [odds ratio (OR) 2.28, 95 % confidence interval (CI) 1.53-3.41], age ≥70 years (OR 2.17, 95 % CI 1.42-3.32), no acute revascularization (OR 2.02, 95 % CI 1.33-3.08), prior stroke/transient ischemic attack (OR 1.90, 95 % CI 1.09-3.30), peripheral arterial disease (OR 1.86, 95 % CI 1.12-3.10), heart rate >85/min (OR 1.82, 95 % CI 1.23-2.71), chronic obstructive lung disease (OR 1.77, 95 % CI 1.01-3.10) and HDL cholesterol <40 mg/dl (OR 1.75, 95 % CI 1.15-2.67). CONCLUSIONS: In patients surviving AMI and treated with contemporary guideline-adherent therapy, 1-year mortality was low. Nevertheless, traditional risk factors such as ejection fraction <45 %, older age, no acute revascularization and comorbidities were the strongest predictors of long-term mortality supporting the findings from previous studies.

Oxygen Kinetics and Heart Rate Response during Early Recovery from Exercise in Patients with Heart Failure.

Background. The purpose of this study was to assess the post-exercise O(2) uptake and heart rate response in patients with heart failure (HF) in comparison to healthy individuals. Methods and Results. Exercise testing of all subjects was conducted according to the RITE-protocol. The study subjects were classified according to their peak oxygen uptake (peak VO(2)) in four groups: healthy individuals with a peak VO(2) >22 mL/kg/min (group 1, n: 50), and patients with HF and a peak VO(2) of 18-22 mL/kg/min, (group 2, n: 48), 14-18 mL/kg/min (group 3, n: 57), and <14 mL/kg/min (group 4, n: 31). Both peak VO(2) and HR declined more slowly in the patients with HF than in the normal subjects. Recovery of VO(2) and HR followed monoexponential kinetics in the early post-recovery phase. This enabled the determination of a time constant for both HR and VO(2) (TC VO(2) and TC HR). From group 1 to 4 there was a prolongation of the time constant for VO(2) and HR: TC VO(2) (group 1: 110 ± 34, group 2: 197 ± 43, group 3: 238 ± 80, and group 4: 278 ± 50 sec), and TC HR (group 1: 148 ± 82, group 2: 290 ± 65, group 3: 320 ± 58, and group 4: 376 ± 55 sec). Conclusion. The rate of decline of VO(2) and HR in the early post-exercise phase is inversely related to the peak VO(2). The time constant for oxygen uptake (TC VO(2)) and heart rate (TC HR) might prove a useful parameter for more precise monitoring and grading of HF.

In-hospital outcomes after elective and non-elective percutaneous coronary interventions in hospitals with and without on-site cardiac surgery backup.

BACKGROUND: Guidelines recommend on-site surgery backup (SB) when elective percutaneous coronary intervention (PCI) is performed. The evidence for this recommendation is however weak. OBJECTIVES: The objective of the present study was to compare clinical outcomes in patients undergoing PCI in hospitals with SB or without surgery backup (non-SB). METHODS: Prospective German PCI registry in 36 hospitals throughout Germany. Consecutive procedures were collected and analyzed centrally. RESULTS: In 2006, a total of 23,148 patients were included; 12,465 patients (53.8%) in 11 hospitals with SB and 10,683 patients (46.2%) in 25 hospitals without on-site cardiac SB. Both patient groups were well-balanced with regard to age and gender. SB hospitals had more patients with ACS (OR 1.29; 95%CI 1.23-1.36) and less patients with stable angina (OR 0.78; 95%CI 0.74-0.82) than non-SB hospitals. There was no indication of a clinically relevant differential outcome for in-hospital death, MACE, non-fatal MI, non-fatal stroke/TIA, or emergency CABG between SB and non-SB hospitals for neither patients with ACS nor stable angina except for emergency CABG in ACS patients (more frequent in SB hospitals, OR 2.29; 95%CI 1.02-5.13). CONCLUSIONS: There was no evidence of an excess risk associated with PCI-procedures performed in non-SB hospitals.

Clopidogrel in addition to aspirin reduces one-year major adverse cardiac and cerebrovascular events in unselected patients with non-ST segment elevation myocardial infarction.

OBJECTIVES: We sought to assess the effect of clopidogrel on one-year ischemic events in unselected patients with NSTEMI. METHODS: We analysed data of consecutive patients with acute NSTEMI treated with aspirin or aspirin plus clopidogrel, who were prospectively enrolled in the ACOS registry. RESULTS: A total of 4290 patients were included, 2171 were treated with aspirin and 2119 with aspirin plus clopidogrel. In the univariate analysis in-hospital (13.7% versus 6.3%, P<0.001) and one-year (28.1% versus 15.6 %, P<0.001) mortality and the combined endpoint of death, non-fatal myocardial infarction and non-fatal stroke was significantly lower in the clopidogrel group. There was a significant increase in in-hospital bleeding complications with clopidogrel (5.4 % versus 3.3 %, P<0.05). In the multivariable propensity score analysis adjusted for baseline variables the odds ratio for the one-year combined endpoint was significantly reduced (odds ratio 0.69, 95% CI: 0.64-0.74) in the aspirin plus clopidogrel group. CONCLUSION: In clinical practice, early therapy with clopidogrel, in addition, to aspirin in patients with NSTEMI is associated with a significant reduction of the combined endpoint of death, non-fatal reinfarction and non-fatal stroke after one year. This advantage was associated with an increase in major in-hospital bleeding complications.

Mahaim fibre coexisting with anomalous origin of the left main coronary artery from the right aortic sinus and an interarterial course.

We present the case of a 45-year-old female with a normal heart, who exhibited an episode of a broad QRS tachycardia that was initially suggested to be sustained ventricular tachycardia. Coronary angiography showed the left main stem originating from the right aortic sinus with an interarterial course between aorta and right ventricular outflow tract. Electrophysiological study revealed the presence of a right atriofascicular accessory pathway with decremental antegrade conduction (Mahaim bundle), which was successfully ablated.

Evaluation of hospitals regarding outcomes and baseline risk -- an application to percutaneous coronary intervention.

UNLABELLED: Monitoring of hospital performance is increasingly used in the process of improving the quality of health care. Various approaches to quality assessment and publication of the results are discussed. Therefore, a method acceptable for clinicians in the hospitals is urgently needed. As the case mix of the patients differs considerably across hospitals, any assessment based on outcome measures has to be adjusted for the patients' risk profiles. We use a method of calculation and presentation that relates the observed complication rate of one centre to the mean rate that would be expected for similar patients in the other centres. We argue that this procedure might especially meet the demands of clinicians in the centres. Data from 44 hospitals in the German Cypher Stent Registry are used to exemplify the proposed procedure. RESULTS: A large variation in the cumulative incidence of MACE within 6 months (range 0-12.2%) as well as in the prevalence of selected risk factors was observed across hospitals. Using a logistic prediction model, the differences in risk profiles of the patient populations in the centres resulted in a wide range of expected MACE rates (2.55-5.44%). The outcome of seven centres differed significantly from the expectation. CONCLUSION: In comparisons of the outcome quality of hospitals, adjustment for the patients' baseline risk by an appropriate method is indispensable.

Highly purified omega-3 fatty acids for secondary prevention of sudden cardiac death after myocardial infarction-aims and methods of the OMEGA-study.

INTRODUCTION: During the last decades a large body of data has been accumulated indicating omega-3 fatty acids to exert beneficial effects on the prognosis of patients with cardiovascular disease. Especially, omega-3 fatty acids are regarded to be effective in reducing the risk of sudden cardiac death after acute myocardial infarction. However, treatment of acute myocardial infarction and secondary prevention considerably have been improved within the past years including early revascularization by PCI, the routine use of beta-blockers, statins and ACE-inhibitors as well as cardiac rehabilitation for improving life style measures. To date, there exists no controlled randomized trial testing the prognostic effect of omega-3 fatty acids after acute myocardial infarction in a double blind regimen under the conditions of modern treatment of myocardial infarction. MATERIALS AND METHODS: The present study therefore evaluates the effect of highly purified omega-3 fatty acid ethylesters (omega-3-acid ethyl esters 90=Zodin) on the rate of sudden cardiac death within 1 year after acute myocardial infarction. Secondary endpoints are total mortality, non-fatal cardiovascular events, rhythm abnormalities in holter monitoring and depression score. RESULT AND CONCLUSION: The recruitment-period started in October 2003 and is expected to last until December 2006. The results of the study are therefore expected for the beginning of 2008, when all patients will have completed the 12-months follow up-period.

Actual clinical practice of exercise testing in consecutive patients after non-ST-elevation myocardial infarction: results of the acute coronary syndromes registry.

BACKGROUND: Exercise testing has been advocated for risk stratification and determination of therapeutic strategies after acute myocardial infarction. Frequency and therapeutic impact of exercise testing after non-ST-elevation myocardial infarction (NSTEMI) in actual clinical practice, however, is not known. METHODS AND RESULTS: From the German acute coronary syndrome (ACOS) registry patients with acute NSTEMI (n = 5281) were evaluated: 20.8% of patients (1097/5281) had predischarge exercise testing, and from these tests 33.5% (367/1097) were positive. The strongest predictors for renunciation of predischarge exercise testing were ejection fraction under 40%, age over 70 years and stroke history. In-hospital coronary angiographies or percutaneous coronary interventions were not associated with a lower rate of exercise testing. During 1-year follow-up all-cause mortality was 13.6% in patients without and 5.1% in patients with exercise test respectively (P < 0.0001). In patients with positive exercise test 1-year mortality was 6.5%, in patients with negative exercise test 4.4% (P = 0.13). During follow-up no significant difference was found in the rate of coronary revascularizations between patients either with positive or negative exercise tests. Furthermore, no significant difference was found in the rate of death and revascularizations comparing different groups of exercise capacity. CONCLUSIONS: After NSTEMI in Germany the majority of patients do not get predischarge exercise testing, although this group appears to be of special risk for fatality during follow-up. Furthermore, in actual clinical practice, neither exercise induced signs of ischemia nor exercise capacity have a significant impact on the rate of revascularization procedures during follow-up.

Effect of clopidogrel on 1-year mortality in hospital survivors of acute ST-segment elevation myocardial infarction in clinical practice.

AIMS: We sought to assess the effect of clopidogrel on clinical events 1 year after discharge in survivors of ST-elevation myocardial infarction (STEMI) in clinical practice. METHODS AND RESULTS: We analysed data of consecutive survivors of acute STEMI and either concomitant therapy with aspirin or aspirin plus clopidogrel at discharge, who were prospectively enrolled in the Acute Coronary Syndromes (ACOS) registry between July 2000 and November 2002. A total of 5886 (3795 with and 2091 without clopidogrel) patients were included into this analysis. Patients were divided into three groups according to the initial reperfusion therapy: no reperfusion therapy (n=1445), fibrinolysis (n=1734), or primary PCI (n=2707). The multivariable analysis for 12+2 month mortality after discharge using the propenstiy score with adjustment for baseline characteristics and treatments (age, sex, diabetes mellitus, hypertension, prior MI, hyperlipidaemia, renal insufficiency, cardiogenic shock, heart rate, systolic blood pressure, anterior infarct location, reduced left ventricular function, elective revascularization, beta-blockers, statins, ACE-inhibitors) showed that mortality was significantly lower in the aspirin plus clopidogrel group compared with the aspirin group in the total group and patients with reperfusion therapy [total group odds ratio (OR) 0.48, 95% confidence interval (CI) 0.48-0.61; no reperfusion therapy OR 0.96, 95% CI 0.65-1.45; fibrinolysis OR 0.53, 95% CI 0.32-0.87; primary percutaneous coronary intervention OR 0.38, 95% CI 0.23-0.62]. CONCLUSION: In clinical practice, adjunctive therapy with clopidogrel, in addition to aspirin, in survivors after STEMI is associated with a reduction in 1-year mortality in patients treated with early reperfusion therapy.