Multicenter randomized trial of facilitated percutaneous coronary intervention with low-dose tenecteplase in patients with acute myocardial infarction: the Athens PCI trial.

OBJECTIVES: To examine the safety and efficacy of low-dose tenecteplase, administered before facilitated percutaneous coronary intervention (PCI) to restore Thrombolysis In Myocardial Infarction (TIMI) grade 2 or 3 blood flow in the infarct related artery (IRA) in patients with ST elevation myocardial infarction (STEMI) scheduled to undergo PCI with a shortest anticipated delay of 30 min. BACKGROUND: PCI preceded by administration of glycoprotein IIb/IIIa inhibitors, full-dose thrombolytics, or both, is associated with no benefit or a higher incidence of adverse events than PCI alone. METHODS: Patients with STEMI < 6 hr in duration were randomly assigned to PCI preceded by tenecteplase, 10 mg (facilitated PCI group, n = 143) versus standard PCI (control group, n = 141). All patients received aspirin and unfractionated heparin (70 IU/kg bolus) at time of randomization. Both groups received IIb/IIIa inhibitors in the catheterization laboratory and for at least 20 hr after PCI. RESULTS: The median door-to-balloon time was 122 min (91-175) in the facilitated PCI versus 120 min (89-175) in the control group. IRA patency on arrival in the catheterization laboratory was 59.5% in the facilitated PCI (24% TIMI-2, 35% TIMI-3), versus 37% in the control (8% TIMI-2, 29% TIMI-3) group (P = 0.0001). During hospitalization, 9 patients (6%) died in the facilitated PCI versus 5 patients (3.5%) in the control group (P = 0.572). A single patient in the facilitated PCI group suffered a non-fatal ischemic stroke. CONCLUSIONS: Facilitated PCI with low-dose tenecteplase in patients presenting with STEMI was associated with a high IRA patency rate before PCI.

Propranolol Versus Metoprolol for Treatment of Electrical Storm in Patients With Implantable Cardioverter-Defibrillator.

BACKGROUND: Electrical storm (ES), characterized by unrelenting recurrences of ventricular arrhythmias, is observed in approximately 30% of patients with implantable cardioverter-defibrillators (ICDs) and is associated with high mortality rates. OBJECTIVES: Sympathetic blockade with ß-blockers, usually in combination with intravenous (IV) amiodarone, have proved highly effective in the suppression of ES. In this study, we compared the efficacy of a nonselective ß-blocker (propranolol) versus a ß1-selective blocker (metoprolol) in the management of ES. METHODS: Between 2011 and 2016, 60 ICD patients (45 men, mean age 65.0 ± 8.5 years) with ES developed within 24 h from admission were randomly assigned to therapy with either propranolol (160 mg/24 h, Group A) or metoprolol (200 mg/24 h, Group B), combined with IV amiodarone for 48 h. RESULTS: Patients under propranolol therapy in comparison with metoprolol-treated individuals presented a 2.67 times decreased incidence rate (incidence rate ratio: 0.375; 95% confidence interval: 0.207 to 0.678; p = 0.001) of ventricular arrhythmic events (tachycardia or fibrillation) and a 2.34 times decreased rate of ICD discharges (incidence rate ratio: 0.428; 95% CI: 0.227 to 0.892; p = 0.004) during the intensive care unit (ICU) stay, after adjusting for age, sex, ejection fraction, New York Heart Association functional class, heart failure type, arrhythmia type, and arrhythmic events before ICU admission. At the end of the first 24-h treatment period, 27 of 30 (90.0%) patients in group A, while only 16 of 30 (53.3%) patients in group B were free of arrhythmic events (p = 0.03). The termination of arrhythmic events was 77.5% less likely in Group B compared with Group A (hazard ratio: 0.225; 95% CI: 0.112 to 0.453; p < 0.001). Time to arrhythmia termination and length of hospital stay were significantly shorter in the propranolol group (p < 0.05 for both). CONCLUSIONS: The combination of IV amiodarone and oral propranolol is safe, effective, and superior to the combination of IV amiodarone and oral metoprolol in the management of ES in ICD patients.

Suppression by propranolol and amiodarone of an electrical storm refractory to metoprolol and amiodarone.

A 60-year-old male patient with ischemic cardiomyopathy experienced an electrical storm 1 month after implantation of an internal cardioverter-defibrillator. Recurrent life-threatening episodes of ventricular tachycardia persisted despite maximal antiarrhythmic theraphy with amiodarone, metoprolol and mexiletine. After a total of more than 500 cardioversions, all antiarrhythmic medications were withdrawn, and the nonselective beta-blocker propranolol was initiated. Electrical stability was achieved and the patient was discharged on propranolol 400 mg/day. Two months later, a second arrhythmia cluster occurred that was controlled by the addition of amiodarone. The patient remains free of arrhythmia 15 months after the event with the combination of propranolol and amiodarone.

Programmed ventricular stimulation in patients with idiopathic dilated cardiomyopathy and syncope receiving implantable cardioverter-defibrillators: a case series and a systematic review of the literature.

BACKGROUND: The role of programmed ventricular stimulation (PVS) in patients with idiopathic dilated cardiomyopathy (DCM) and syncope receiving implantable cardioverter-defibrillators (ICD) remains controversial. METHODS AND RESULTS: Between 1994 and July 2002, 20 patients with DCM and syncope underwent PVS and ICD implantation at the Onassis Cardiac Surgery Center or the Alexandra General Hospital. At PVS 10 patients had inducible sustained monomorphic ventricular tachycardia (SMVT), 3 patients had inducible sustained polymorphic ventricular tachycardia or ventricular fibrillation, and 7 patients had no inducible arrhythmia. The latter 7 patients received an ICD because of clinical occurrence of ventricular tachycardia (n=5) or fibrillation (n=2). Mean age was 55+/-14 years; 80% were men. During a mean follow-up of 2.8+/-2.3 years, 12 of the 20 patients received an appropriate shock. The incidence of appropriate shocks at 1 and 3 years was 69% and 84% in the inducible SMVT group, and 56% and 67% in the group without inducible SMVT (p=0.93, log rank test). Overall survival was similar in both groups (p=0.53). In a systematic review of the published literature 18 of 75 (24%) patients with DCM, syncope and a negative PVS had an appropriate ICD shock after a mean follow-up of 27 months. CONCLUSION: PVS has a limited role in risk stratification of patients with DCM and syncope.

Radiofrequency ablation procedures in Greece: initial experience and results from the national registry 2008-2010.

INTRODUCTION: In 2008 the radiofrequency ablation procedures (RFA) registry of the Hellenic Cardiological Society (HCS) was created. This is a dynamic, web-based application, which acts as the interface for storing and retrieving patients' demographic data and ablation procedures. Access to the site is permitted only to registered users. The purpose of this study is to report the results of RFA procedures performed in Greece over the 2008-2010 period. METHODS: There are 27 centers in 24 hospitals that are licensed to perform RFA in Greece. During the period 2008-2010, 3541 RFA procedures were performed in 3344 patients in 23 centers. Four centers did not contribute data at all for various reasons. It is interesting that nearly 50% of the total number of procedures were performed at 3 high volume centers (>100 cases/year). RESULTS: The most common procedure was slow pathway ablation for atrioventricular reentrant tachycardia, the second was ablation of accessory pathway related tachycardias, and the third was ablation of atrial fibrillation. Success rates were high (92.1%), the complication rate was 3% (serious complications <1%) and total relapse rate was 8.7% at six months' follow up. CONCLUSIONS: The electronic RFA registry in Greece confirmed that all RFA procedures are performed in Greece with high success and low complication rates, comparable to the European and US standards. The experience and results from the first three-year period using the registry are very interesting and encouraging, thus indicating the need for development of similar databases at the national level.

Correlation between myocardial enzyme serum levels and markers of inflammation with severity of coronary artery disease and Gensini score: a hospital-based, prospective study in Greek patients.

BACKGROUND: Our objective was to associate serum levels of myocardial enzymes and inflammatory biomarkers with severity of coronary artery disease (CAD). PATIENTS AND METHODS: 123 patients participated in our study, including 65 cases of acute myocardial infarction (MI), 27 cases of newly diagnosed CAD--without MI--and 31 controls. In all subjects, myocardial serum enzyme levels (creatine phosphokinase, aspartate aminotransferase, lactate dehydrogenase) and inflammatory indices (C-reactive protein, fibrinogen, white blood cells, and erythrocyte sedimentation rate) were measured. Patients were all submitted to coronary angiography and CAD severity was evaluated by Gensini score. RESULTS: Significant differences concerning enzyme serum levels and inflammatory indices were found to exist between the three study groups, being highest among patients with acute MI (p < 0.001). A significant association was demonstrated between Gensini score and serum enzyme levels as well as inflammatory biomarkers. CONCLUSIONS: Our findings suggest that serum levels of myocardial enzymes and inflammatory indices correlate with CAD severity in Greek patients.