Clinical and angiographic profiles and six months outcomes of smokers with acute ST segment elevation myocardial infarction undergoing primary percutaneous coronary angioplasty

Background Outcomes of primary percutaneous coronary intervention (PCI) for acute STEMI (ST-segment elevation myocardial infarction) in smokers are expected to be better than non-smokers as for patients of acute STEMI with or without fibrinolytic therapy. Objectives This comparative study was designed to evaluate the outcomes of primary PCI in patients with acute STEMI in smokers and non-smokers. Clinical and angiographic profile of the two groups was also compared. Methods Over duration of two year, a total of 150 consecutive patients of acute STEMI eligible for primary PCI were enrolled and constituted the two groups [Smokers (n = 90), Non-smokers (n = 60)] of the study population. There was no difference in procedure in two groups. Results In the present study of acute STEMI, current smokers were about a decade younger than non-smokers (p value = 0.0002), majority were male (98.9% vs 56.6%) were male with a higher prevalence of hypertension and diabetes mellitus (61.67% vs 32.28% and 46.67% vs 14.44%, p = 0.001) respectively. Smokers tended to have higher thrombus burden (p = 0.06) but less multi vessel disease (p = 0.028). Thirty day and six month mortality was non-significantly higher in smokers 4.66% vs 1.33% (p = 0.261) and 5.33% vs 2.66% (p = NS) respectively. Rate of quitting smoking among smokers was 80.90% at 6 months. Conclusion The study documents that smokers with acute STEMI have similar outcomes as compared to non smokers with higher thrombus burden and lesser non culprit artery involvement. Smokers present at much younger age emphasizing the role of smoking cessation for prevention of myocardial infarction.

Clinical Evaluation of an Indigenous Paclitaxel-Eluting Stent in De NovoCoronary Artery Stenosis.

BACKGROUND, Drug-eluting stents have enabled considerable reduction in restenosis in patients subjected to angioplasty. However, in view of high cost of drug-eluting stents, efforts to develop medicated stents at reduced cost using alternative polymers in Indian setting are imperative. Hence a multi-center study was undertaken to evaluate the safety and efficacy of the indigenously developed paclitaxel-eluting RELEASE-T stent. METHODS, The study included 100 patients (male:86, Female:14) who were undergoing angioplasty for various indications at four centres viz. Delhi, Hyderabad, Pune and Warangal. The age range was 29 - 76 years; 37 patients were diabetic. All patients were pre-treated with aspirin 150-325 mg plus clopidogrel 75 mg daily four days before procedure or clopidogrel alone. Aspirin was continued indefinitely. RESULTS, Direct stenting ws done in majority of patients. One patient, in whom stent could not be delivered, received only baloon angioplasty. Sixty-four patients had stenting of left anterior descending artery. The stent diameter ranged from 2.5 to 3.5 mm, and the length, 15 to 20 mm. All patients were followed up at 1,3 and 6 months. There was two deaths: one had subacute thrombosis on both stents, and the other (who was HIV positive) had sudden cardiac death. The 6-month rate of major adverse cardiac events was 4% and target lesion revascularization rate ws 2%. CONCLUSION, This ulti-locational study brings out that the use of indigenously developed paclitaxel-eluting stent is safe and clinically efficacious.

The "hybrid" approach for revascularisation: direct myocardial revascularisation and coronary angioplasty.

We report the cases of two patients where catheter-based laser direct myocardial revascularisation has been coupled with conventional coronary angioplasty at the same sitting using the Biosense left ventricular electromechanically guided laser procedure. In both the cases, the non-revascularizable ischaemic target zone was identified using left ventricular electromechanical mapping signals, and Ho: YAG laser channels were placed at the designated target lesion following successful coronary stenting. The results did not show any procedural complications. This preliminary report suggests the feasibility and safety of this "hybrid" percutaneous approach for myocardial revascularisation.

Acute haemodynamic effects of nicorandil in patients with chronic severe regurgitant valvular lesions.

The haemodynamic effects of nicorandil, a new balanced vasodilator exhibiting nitrate-like as well as potassium-channel opening activity in patients with chronic severe valvular lesions have not been reported. We studied the acute effect of nicorandil on haemodynamics in 12 stable patients (6 males, 6 females; mean age 23.5 +/- 4.6 years) with chronic severe valvular regurgitation (8 mitral, 4 aortic). All patients were studied in resting, supine and fasting states. All cardioactive drugs were withdrawn five days prior to the study. Intra-arterial line was placed and thermodilution catheter was positioned in the pulmonary artery. Haemodynamic parameters recorded at baseline and at 30, 60, 90 and 120 minutes following a single oral dose of 20 mg nicorandil revealed no significant change in the heart rate while systemic pressures showed a small decline (p < 0.05). There was significant reduction in systolic, diastolic and mean pulmonary artery pressures (p < 0.001). The mean cardiac index increased from 3.16 L/min/m2 at baseline to 3.77 L/min/m2 at 60 minutes. Both the pulmonary and systemic vascular resistance indices reduced significantly, the peak fall being 18 percent and 29 percent, respectively. Maximal changes were observed at 60 to 90 minutes following administration of nicorandil. No adverse effect of nicorandil occurred during the study. We conclude that nicorandil has a favourable acute haemodynamic effect in patients with chronic severe valve regurgitation. Its long-term use in valvular lesions should be explored further.

Changes in circulatory biogenic amines during head-up tilt testing in neurocardiogenic syncope.

The pathogenesis of neurocardiogenic syncope is not completely understood. To examine the possible role of biogenic amines in patients with neurocardiogenic syncope, 18 consecutive patients (age 30 +/- 13 years, 15 males, 3 females) of unexplained syncope were subjected to Head-Up Tilt Testing (HUTT). Blood was sampled by an indwelling cannula at baseline, end of tilt test (or at syncope) and 1 min after returning to the supine position. Biogenic amines, epinephrine (E), norepinephrine (NE), serotonin (5-HT) and their metabolites, homovanillic acid (HVA) and 5-hydroxy indole acetic acid (5-HIAA), were measured in the serum after serial organic phase extraction by high-performance liquid chromatography (HPLC) using ultraviolet detection at a wavelength of 280 nm. Twelve patients were found to be HUTT negative while 6 patients were HUTT positive. Baseline E, NE and 5-HT levels were significantly greater in the HUTT positive patients [E 510 +/- 154 versus 302 +/- 96 pg/ml (p < 0.01), NE 253 +/- 99 versus 159 +/- 62 pg/ml (p < 0.05), 5-HT 174 +/- 32 versus 118 +/- 22 pg/ml (p < 0.01)]. E and HVA levels at the end of the test were significantly higher in HUTT positive patients [E 788 +/- 268 versus 465 +/- 119 pg/ml (p < 0.01), HVA 308 +/- 91 versus 112 +/- 12 pg/ml (p < 0.001)]. A significantly greater rise of E from the baseline was observed in HUTT positive patients (510 +/- 154 versus 112 +/- 12 pg/ml (p < 0.01)]. The increase in the levels of E and HVA both at baseline and after the tilt test, without a corresponding rise in NE levels indicates enhanced activity of the adrenomedullary axis which is not paralleled by NE release from sympathetic nerve endings in patients of neurocardiogenic syncope.

Ischaemic preconditioning: an intracoronary electrocardiographic study.

Brief episodes of myocardial ischaemia may enhance the tolerance to subsequent ischaemic episodes. This phenomenon has been called ischaemic preconditioning. Intracoronary electrocardiograms (ECG) were obtained during coronary angioplasty in 15 patients (13 males, 2 females; age 49 +/- 12 years) by attaching the external end of the balloon angioplasty guide wire to the V1 lead on the surface electrocardiogram. Surface leads I, II and III and intracoronary ECG were recorded at baseline and during balloon occlusion. The pattern of ST segment change during the first and subsequent inflation were compared. A significant reduction in ST segment deviation was observed in intracoronary ECG between the first and second inflation (10 +/- 1 vs 5 +/- 3 mm, p < 0.05). However, surface ECG showed no significant difference in ST segment deviation between the two inflations (3 +/- 1 vs 2 +/- 1 mm, p = NS). Thus, intracoronary ECG detects acute ischaemia more readily as compared to the routinely monitored surface ECG. A significant reduction noted in ST segment deviation during the second inflation suggests the phenomenon of ischaemic preconditioning in humans.

A study of platelet aggregation, thromboxane A2 and prostacyclin in central aortic and coronary sinus blood in ischemic heart disease.

Aortic and coronary sinus platelet aggregation, thromboxane A2 (TXA2) and prostacyclin (PG12) levels were studied in fourteen patients of stable angina (SA), six of vasopastic angina (VA) and six control subjects (C). Patients of SA were studied at rest and during incremental atrial pacing and patients with VA were studied at rest and during various stages of vasospasm. Platelet aggregation was studied with different working concentrations of ADP, epinephrine and collagen. TX A2 and PGI2 concentrations were estimated by measuring levels of their stable metabolites viz. thromboxane B2 (TXB2) and 6-keto prostaglandin F1 alpha (PGF1 alpha) respectively. Platelet aggregation was increased in SA and VA patients (p < 0.01) and further increase was seen during vasospasm (p < 0.001). However, it failed to increase on incremental atrial pacing. Similarly, TXB2 and PGF1 alpha levels were raised in SA and VA patients. While TXB2 further increased during vasospasm but not during atrial pacing. PGF1 infinity failed to rise with either. Thus platelets are in an activated state in SA and VA. This activated state is a cause and not an effect in SA and VA. An imbalance in the levels of TXA2 and PG12 could account for the vasospasm.

Alkaptonuria.

A case of alkaptonuria with its various sequelae in the form of ochronosis, ochronotic arthropathy, spondylitis and prostatic calculi is reported. The case is of interest as it presented with hepatocellular failure and hepatitis B surface antigenaemia.