Assessing the role of eptifibatide in patients with diffuse coronary disease undergoing drug-eluting stenting: the INtegrilin plus STenting to Avoid myocardial Necrosis Trial.

BACKGROUND: The optimal antiplatelet regimen in elective patients undergoing complex percutaneous coronary interventions (PCIs) is uncertain. We aimed to assess the impact of glycoprotein IIb/IIIa (GpIIb/IIIa) inhibition with eptifibatide in clinically stable subjects with diffuse coronary lesions. METHODS: Patients with stable coronary artery disease undergoing PCI by means of implantation of >33 mm of drug-eluting stent were single-blindedly randomized to heparin plus eptifibatide versus heparin alone. The primary end point was the rate of abnormal post-PCI creatine kinase-MB mass values. Secondary end points were major adverse cardiovascular events (MACEs) (ie, cardiac death, myocardial infarction, or urgent revascularization) and MACE plus bailout GpIIb/IIIa inhibitor use. RESULTS: The study was stopped for slow enrollment and funding issues after including a total of 91 patients: 44 were randomized to heparin plus eptifibatide, and 47, to heparin alone. Analysis for the primary end point showed a trend toward lower rates of abnormal post-PCI creatine kinase-MB mass values in the heparin-plus-eptifibatide group (18 [41%]) versus the heparin-alone group (26 [55%], relative risk 0.74 [95% CI 0.48-1.15], P = .169). Similar nonstatistically significant trends were found for rates of MACE, their components, or MACE plus bailout GpIIb/IIIa inhibitors (all P > .05). Notably, heparin plus eptifibatide proved remarkably safe because major bleedings or minor bleeding was uncommon and nonsignificantly different in both groups (all P > .05). CONCLUSIONS: Given its lack of statistical power, the INSTANT study cannot definitively provide evidence against or in favor of routine eptifibatide administration in stable patients undergoing implantation of multiple drug-eluting stent for diffuse coronary disease. However, the favorable trend evident for the primary end point warrants further larger randomized studies.

Clinical efficacy and safety of intracoronary vs. intravenous abciximab administration in STEMI patients undergoing primary percutaneous coronary intervention: a meta-analysis of randomized trials.

Adjunctive therapy with abciximab has been proven to reduce mortality and reinfarction in patients with ST-elevation myocardial infarction (STEMI) referred to invasive management. Standard abciximab regimen consists of an intravenous (IV) bolus followed by a 12-h IV infusion. Experimental studies and small clinical trials suggest the superiority of intracoronary (IC) injection of abciximab over the IV route. We aimed to perform a meta-analysis of randomized controlled trials to assess the clinical efficacy and safety of IC vs. IV abciximab administration in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). The primary endpoint was mortality, while recurrent myocardial infarction and target vessel revascularization (TVR) were selected as secondary endpoints. The safety endpoint was the risk of major bleeding complications. A total of six randomized trials were finally included in the meta-analysis, enrolling a total of 1246 patients. Compared to IV route, IC abciximab was associated with a significant reduction in mortality (odds ratio, OR [95% confidence interval (CI)] =0.43 [0.20-0.94], p=0.03), and TVR (OR [95% CI] =0.53 [0.29-0.99], p=0.05). No differences in terms of recurrent myocardial infarction (OR [95% CI] =0.54 [0.23-1.28], p=0.17) or major bleeding complications (OR [95% CI] =0.91 [0.46-1.79], p=0.79) were observed between the two strategies. The present meta-analysis showed that IC administration of abciximab is associated with significant benefits in mortality at short-term follow-up compared to IV abciximab administration, without any excess of major bleeding in STEMI patients undergoing PPCI. However, further trials are warranted to establish the optimal strategy of abciximab treatment in this setting.

[Robotic percutaneous coronary intervention: current evidence, practical aspects and future perspectives]. / L'angioplastica coronarica robotica: evidenze scientifiche, aspetti pratici e prospettive future.

Robotic percutaneous coronary intervention (R-PCI) is an emerging technology designed to improve operator safety and procedural precision. The interventional cardiologist is able to manipulate guidewires, catheters and devices from a specific cockpit. A number of studies evaluating R-PCI have shown high procedural success rates with low complications. R-PCI advantages include the possibility to perform an accurate stent positioning, to reduce the operator radiation exposure and orthopedic injuries. However, there is a limited experience regarding R-PCI in complex anatomies, that may still require manual assistance. Moreover, the technique is limited by current incompatibility with specific materials, the lack of tactile feedback and the possibility to robotically manage only one wire/device at the same time. Globally, R-PCI is a novel approach with future interesting implications, but further investigations are necessary to overcome current limitations.

Ostial and midshaft lesions vs. bifurcation lesions in 1111 patients with unprotected left main coronary artery stenosis treated with drug-eluting stents: results of the survey from the Italian Society of Invasive Cardiology.

AIMS: In this study, we compared the cumulative risk of major adverse cardiac events (MACE) of patients with distal unprotected left main coronary artery (ULMCA) stenosis with those of patients with ostial and midshaft lesions treated with drug-eluting stent (DES). METHODS AND RESULTS: The survey promoted by the Italian Society of Invasive Cardiology on ULMCA stenosis was an observational study involving 19 high-volume Italian centres. We enrolled 1111 patients with ULMCA stenosis treated with DES. Major adverse cardiac events were defined as death, myocardial infarction, and target lesion revascularization. Three hundred and thirty-four patients had ostial or midshaft lesions (group 1) and 777 bifurcations (group 2). The adjusted hazards ratio of the risk of 2 year MACE of patients in group 2 vs. patients in group 1 was 1.50 (P = 0.024). However, we observed that there was a significant difference between patients with bifurcations treated with two stents and those in group 1 (P = 0.001), but not between patients with bifurcations treated with one stent and those in group 1 (P = 0.38). CONCLUSION: Patients with bifurcations have a worse outcome than patients with ostial and midshaft lesions. However, the technique used to treat bifurcations has a significant impact on clinical outcomes.

Are drug-eluting stents superior to bare-metal stents in patients with unprotected non-bifurcational left main disease? Insights from a multicentre registry.

AIMS: To compare long-term clinical outcome following drug-eluting stents (DES) or bare-metal stents (BMS) implantation on lesions located at the ostium or the shaft of the left main in a large real-world population. The advent of DES decreased the risk of unprotected left main coronary artery (ULMCA) restenosis when compared with BMS, but it is unclear if this advantage continues when non-bifurcational lesions are considered. METHODS AND RESULTS: The GISE-SICI registry is a retrospective, observational multicentre registry promoted by the Italian Society of Invasive Cardiology in which 19 high-volume participating centres enrolled 1453 consecutive patients who underwent percutaneous coronary intervention on ULMCA between January 2002 and December 2006. From the registry, a total of 479 consecutive patients with ostial and shaft lesions who underwent DES (n = 334) or BMS (n = 145) implantation were analysed with extensive multivariable and propensity score adjustments. At 3-year follow-up, risk-adjusted survival rates were higher in patients treated with DES than in those treated with BMS. The adjusted hazard ratio (HR) for the risk of mortality after DES implantation relative to BMS implantation was 0.37 (95% CI: 0.15-0.96, P = 0.04). The adjusted HR for the risk of cardiac mortality was 0.31 (95% CI: 0.09-1.04, P = 0.06). The adjusted 3-year rates of target lesion revascularization (TLR) were not significantly lower in the DES group than in the BMS group (P = 0.60). CONCLUSION: In a large population of patients with lesions located at the ostium or the shaft of the left main in a real-world setting, DES were associated with favourable clinical outcomes when compared with BMS, although there was no evidence of a significant reduction in TLR with DES vs. BMS.

Sirolimus-eluting versus uncoated stents in acute myocardial infarction.

BACKGROUND: Sirolimus-eluting stents reduce rates of restenosis and reintervention, as compared with uncoated stents. Data are limited regarding the safety and efficacy of such stents in primary percutaneous coronary intervention (PCI) for acute myocardial infarction with ST-segment elevation. METHODS: We performed a single-blind, multicenter, prospectively randomized trial to compare sirolimus-eluting stents with uncoated stents in primary PCI for acute myocardial infarction with ST-segment elevation. The trial included 712 patients at 48 medical centers. The primary end point was target-vessel failure at 1 year after the procedure, defined as target-vessel-related death, recurrent myocardial infarction, or target-vessel revascularization. A follow-up angiographic substudy was performed at 8 months among 174 patients from selected centers. RESULTS: The rate of the primary end point was significantly lower in the sirolimus-stent group than in the uncoated-stent group (7.3% vs. 14.3%, P=0.004). This reduction was driven by a decrease in the rate of target-vessel revascularization (5.6% and 13.4%, respectively; P<0.001). There was no significant difference between the two groups in the rate of death (2.3% and 2.2%, respectively; P=1.00), reinfarction (1.1% and 1.4%, respectively; P=1.00), or stent thrombosis (3.4% and 3.6%, respectively; P=1.00). The degree of neointimal proliferation, as assessed by the mean (+/-SD) in-stent late luminal loss, was significantly lower in the sirolimus-stent group (0.14+/-0.49 mm, vs. 0.83+/-0.52 mm in the uncoated stent group; P<0.001). CONCLUSIONS: Among selected patients with acute myocardial infarction, the use of sirolimus-eluting stents significantly reduced the rate of target-vessel revascularization at 1 year. (ClinicalTrials.gov number, NCT00232830 [ClinicalTrials.gov].).

Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism.

OBJECTIVES: To appraise the impact of AngioJet rheolytic thrombectomy (RT) on angiographic and clinical endpoints in patients with acute pulmonary embolism (PE). BACKGROUND: The management of patients with acute PE and hemodynamic compromise, based mainly on anticoagulant and thrombolytic therapies, is challenging and still suboptimal in many patients. In such a setting, mechanical removal of thrombus from pulmonary circulation holds the promise of significant clinical benefits, albeit remains under debate. METHODS: We retrospectively report on 51 patients referred to our catheterization laboratory and treated with AngioJet RT. Patients were classified according to the degree of hemodynamic compromise (shock, hypotension, and right ventricular dysfunction) to explore thoroughly the degree of angiographic pulmonary involvement (angiographic massive PE was defined as the presence of a Miller index >or= 17) and the impact on angiographic (obstruction, perfusion, and Miller indexes) and clinical (all-cause death, recurrence of PE, bleeding, renal failure, and severe thrombocytopenia) endpoints of AngioJet RT. RESULTS: Angiographic massive PE was present in all patients with shock, whereas patients with right ventricular dysfunction and hypotension showed a similar substantial pulmonary vascular bed involvement. Technical success was obtained in 92.2% of patients, with a significant improvement in obstruction, perfusion and Miller indexes in each subgroup (all P < 0.0001). Four patients reported major bleedings and eight (15.7%) died in-hospital. Laboratory experience was significantly associated to a lower rate of major bleedings. All survivors were alive at long-term follow-up (35.5 +/- 21.7 months) except three who expired due to cancer and acute myocardial infarction. CONCLUSIONS: In experienced hands AngioJet RT can be operated safely and effectively in most patients with acute PE, either massive or submassive, and substantial involvement of pulmonary vascular bed.

Long-term clinical benefit of drug-eluting stents over bare-metal stents in diabetic patients with de novo left main coronary artery disease: results from a real-world multicenter registry.

BACKGROUND: Few data are available on diabetic patients undergoing percutaneous coronary intervention (PCI) in the context of unprotected left main coronary artery (ULMCA) disease. The main goal of this study was to present the long-term relative benefits of using drug-eluting stent (DES) instead of bare-metal stent (BMS) for diabetic patients submitted to percutaneous ULMCA treatment in a large real world multicenter registry. METHODS: The GISE-SICI registry is a retrospective, observational multicenter registry promoted by the Italian Society of Invasive Cardiology in which 19 high-volume participating centers enrolled 1,453 consecutive patients who underwent PCI on ULMCA between January 2002 and December 2006. From the registry, a total of 398 consecutive patients with diabetes mellitus who underwent DES (n = 321) or BMS (n = 77) implantation were analyzed, with extensive multivariable adjustments. RESULTS: At 3-years, use of DES in diabetic patients resulted in no significant differences with respect to death (HR 0.56, 95% CIs 0.24-1.28), myocardial infarction (HR 0.82, 95% CIs 0.21-3.26), and the composite end-point of death or myocardial infarction (HR 0.56, 95% CIs 0.27-1.20). Conversely, DES were associated with significant reduction of target lesion revascularization (TLR, HR 0.33; 95% CIs 0.14-0.80, P = 0.001) rates. CONCLUSIONS: Patients presenting with ULMCA disease in the context of diabetes mellitus who are treated with stent-supported PCI have a significant reduction in the rate of TLR with no increased risk of death or myocardial infarction.

Mechanisms of late stent malapposition after primary stenting in ST-elevation myocardial infarction: a subanalysis of the selection trial.

BACKGROUND: One of the major predictors of late stent malapposition (LSM) is primary stenting in acute myocardial infarction. However, mechanisms of LSM are still under debate. METHODS: Patients with ST-elevation myocardial infarction (STEMI) and enrolled in the SELECTION trial (38 patients in the paclitaxel-eluting stent, PES, and 35 in the bare metal stent, BMS, cohort) were retrospectively analyzed to evaluate LSM, by means of intravascular ultrasound (IVUS) data recorded at the index and 7-month follow-up procedures. RESULTS: Stent malapposition was documented in 21 lesions in 21 patients (28.8%): in 8 of these 21 patients (38.1%) it was LSM. Although statistical significance was not reached, LSM was more frequent after PES than BMS implantation (15.8% vs. 5.7%). LSM was mainly located within the body of the stent (62.5% of the cases). At the LSM segment, a significant increase of vessel area (19.2 +/- 3.3 mm(2) vs. 21.9 +/- 5.3 mm(2), P = 0.04) and a reduction of plaque area (12.6 +/- 4.6 mm(2) vs. 9.1 +/- 3.9 mm(2), P = 0.04) were observed at IVUS between the index and follow-up procedure. CONCLUSIONS: After primary stenting for STEMI, LSM seems to be more frequent after PES rather than BMS implantation. In the STEMI setting, possible mechanisms leading to LSM include positive remodeling and plaque mass decrease.

Is electrocardiography a reliable tool for identifying patients with isthmus-dependent atrial flutter?

AIMS: To verify the reliability of the surface ECG to discriminate between cavotricuspid isthmus-dependent atrial flutter (CTI-AFL) and non-CTI-AFL. METHODS AND RESULTS: We reviewed the ECGs of 186 consecutive patients who underwent catheter ablation of AFL between January 2004 and January 2008. The ECG pattern was defined typical for CTI-AFL, if F-waves were: (i) dominantly negative in the inferior leads and positive in V1 (CCW) or (ii) dominantly positive in the inferior leads and negative in V1 (CW). At the electrophysiological study (EPS), 138 patients (74.2%) had a CTI-AFL and 48 patients (25.8%) had a non-CTI-AFL. A CTI-AFL was found not only in 90.5% of patients having a typical ECG, but also in 40% of patients having an atypical ECG. Thus, a typical AFL ECG showed a sensitivity of 0.83 and a specificity of 0.75 to predict a CTI-AFL, with a positive predictive value of 90.5% and a negative predictive value of 60%. CONCLUSION: Typical AFL ECG is a good predictor of CTI-AFL, and in this case, an ablation procedure can be recommended. On the contrary, an atypical AFL ECG does not rule out a CTI-AFL; so, even in this group of patients, an EPS should not be denied when indicated by the clinical circumstances.

Percutaneous coronary implantation of sirolimus-eluting stents in unselected patients and lesions: clinical results and multiple outcome predictors.

BACKGROUND: Sirolimus-eluting stents (SES) prevent restenosis and repeat percutaneous coronary intervention (PCI), but safety data in unselected patients are limited, especially for intermediate-term follow-up. METHODS: All patients undergoing SES implantation at 4 Italian centers were enrolled into a dedicated database. Baseline, procedural, and outcome data at discharge and at follow-up were abstracted. Outcomes of interest were the occurrence of major adverse cerebrocardiovascular events (MACCE) at 6 months, as well as long-term event-free survival and multivariable event predictors. RESULTS: One thousand four hundred twenty-four patients were enrolled (2,915 lesions, treated with 3,305 stents). Specifically, 1,074 (75.4%) subjects had multivessel disease, 399 (28.1%) had diabetes, 89 (6.3%) had ST-elevation myocardial infarction, and 44 (3.1%) underwent unprotected left main intervention. At 6 months, MACCE had occurred in 121 (9.0%) patients. After a median of 48.7 months (first-third quartile 41.8-55.3), MACCE-free survival was 69.2%+/-2.6%, with definite stent thrombosis occurring acutely in 6 (0.4%), subacutely in 11 (0.8%), after 30 days in 12 (0.8%), and cumulatively in 28 (2.0%). Major multivariable outcome predictors were diabetes (target lesion revascularization [TLR], MACCE), ejection fraction (TLR, MACCE), and maximal balloon length (TLR). CONCLUSIONS: This large cohort of unselected patients supports the overall safety of unrestricted percutaneous SES implantation, as shown by the low rates of stent thrombosis. Event attrition remains, however, high at long-term follow-up, driven mainly by target vessel revascularization, with diabetes and ejection fraction as the most important prognostic factors.

Early and long-term clinical results of AngioJet rheolytic thrombectomy in patients with acute pulmonary embolism.

Anticoagulant and thrombolytic therapies are a mainstay in the management of acute pulmonary embolism (PE), especially when hemodynamic compromise is present. However, systemic drugs cannot achieve timely and effective treatment of acute PE in all patients. In such a setting, mechanical removal of thrombus from the pulmonary circulation holds the promise of significant clinical benefits, although it remains untested. We report early and long-term outcome of patients with massive or submassive acute PE treated with rheolytic thrombectomy by means of the 6Fr Xpeedior AngioJet device at our institution. Three main groups were defined pre hoc: subjects with severe (i.e., shock), moderate, or mild hemodynamic compromise. Technical and procedural successes, obstruction, perfusion and Miller indexes, and clinical events were appraised. In total 25 patients were treated with thrombectomy (8 in severe, 12 in moderate, and 5 in mild hemodynamic compromise). Technical and procedural successes were obtained in all patients, as confirmed by the significant improvement in obstruction, perfusion and Miller indexes overall, and in each subgroup (all p values <0.001). Improvement in obstruction, perfusion, and Miller indexes at the end of the procedure could also be confirmed in patients (n = 8) treated with local fibrinolysis and in the absence of concomitant thrombolysis (n = 17, p <0.05). Four patients died in hospital, all other patients but 1 were safely discharged after an appropriate hospital stay, and all were alive at long-term follow-up (median 61 months). In conclusion, this study supports at early and long-term follow-up the effectiveness and safety of rheolytic thrombectomy for PE.

Effect of comorbidity on coronary reperfusion strategy and long-term mortality after acute myocardial infarction.

BACKGROUND: Chronic comorbidity is a prognostic determinant in ST-segment elevation myocardial infarction (STEMI). This study was aimed at determining to what extent this effect is independent or derives from adoption of different therapeutic strategies. METHODS: Seven hundred forty patients with STEMI hospitalized within 12 hours of symptom onset were enrolled in a population-based registry, in a health district comprising 1 teaching hospital with and 5 district hospitals without percutaneous coronary intervention (PCI) facilities. Three categories of increasing chronic comorbidity score (CS-1, n = 259; CS-2, n = 235; CS-3, n = 246) were identified from age-adjusted associations of comorbidities with 1-year survival. RESULTS: Higher CS was associated with lower direct admission or transferal rates to hospital with PCI. Coronary reperfusion therapy (PCI in 91.5% of 470 cases) was adopted less frequently (P < .001) in CS-3 (41.9%) than CS-2 (69.4%) or CS-1 (78.8%). Compared with conservative therapy (n = 270), reperfusion therapy reduced 1-year mortality in the whole series not significantly (P = .816) in CS-1 but significantly in CS-2 (P = .012) and CS-3 (P = .001). This trend persisted after adjusting for age, Killip class, and acute myocardial infarction location (hazard ratio [HR] = 0.63 [95% CI 0.14-2.80], HR = 0.62 [95% CI 0.31-1.25], and HR = 0.47 [95% CI 0.26-0.86] in CS-1, CS-2, and CS-3, respectively). By hypothesizing an extension of coronary reperfusion therapy utilization rate in CS-2 and CS-3 to that in CS-1, from 21 (crude analysis) to 20 (adjusted analysis) deaths were classified as potentially avoidable. CONCLUSION: Increased mortality in patients with chronic comorbidity and STEMI derives, at least in part, from underutilization of coronary reperfusion therapy, and might be reduced with a more aggressive therapeutic approach.

Timing, setting and incidence of cardiovascular complications in patients with acute myocardial infarction submitted to primary percutaneous coronary intervention.

BACKGROUND: At the Istituto di Clinica Medica Generale e Cardiologia (Florence, Italy), the widespread use of percutaneous coronary intervention (PCI) has markedly changed the hospital course of patients with acute myocardial infarction (AMI). These patients are typically transferred to the coronary care unit (CCU) only after primary PCI, whereas during the thrombolytic era, patients were first admitted to CCU before reperfusion. OBJECTIVES AND METHODS: The incidence, timing and setting of complications from symptom onset to hospital discharge in 689 consecutive AMI patients undergoing PCI were evaluated. RESULTS: Ventricular fibrillation occurred in 11% of patients, and most episodes (94.7%) occurred before or during PCI. Of all patients, 6.3% developed complete atrioventricular block (CAVB), and in 86.3% of these cases, the CAVB occurred before or during PCI; in 94.5%, a CAVB resolution occurred in the catheterization laboratory (CL). Thirty-one patients (4.5%) had impending shock on admission to the CL. Cardiogenic shock developed in 2 9 patients (4.2%), mostly in the prehospital phase or in the CL. Only four patients (less than 1%) developed cardiogenic shock later during their hospital course. Similarly, circulatory and ventilatory support, as well as temporary pacing and cardiac defibrillation, were used mostly in the prehospital phase or in the CL. During the CCU stay, 45 patients (6.5%) had hemorrhagic or vascular complications, and the incidence of post-PCI ischemia and early reocclusion of the culprit vessel were low (2.1% and 0.6%, respectively). Thus, cardiac complications usually associated with AMI were observed mainly before hospital admission or in the CL during the reopening of the target vessel. These complications were rarely observed after a successful PCI. CONCLUSIONS: For AMI patients, the CL is not only the site of PCI, it is also where most life-threatening cardiac complications are observed and treated.

Left main percutaneous coronary intervention in ACS or stable coronary artery disease: acute and long-term results.

BACKGROUND: The aim of this study was to assess in-hospital and long-term results of the novo unprotected left main (UPLM) percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) or stable coronary artery disease (CAD), in an unselected population admitted to a single high- volume cath-lab without on-site cardiac surgery. METHODS: From 2008 to 2011, among 317 PCI performed in patients with the novo UPLM stenosis, 49 patients presented ST-elevation myocardial infarction (STEMI), 152 non ST-elevation MI/unstable angina (NSTEMI/UA), 116 stable CAD. RESULTS: In-hospital mortality was 20% in STEMI, 5.3% in NSTEMI/UA and 1.7% in stable CAD patients (P<0.001). Two-year total mortality was 24.5%, 25.6% and 6% in the 3 groups, and cardiac death was 20%, 13.8% and 3.4% (P=0.002). Left main target lesion revascularization (TLR) was similar in the 3 groups, as the clinically-driven TLR (10% vs. 11% vs. 7.7%, P=0.642), with neither definite nor probable stent thrombosis. Multivariate analysis showed the following independent predictors of 2-year mortality: bare-metal stent use (OR 4.53, P<0.001), Syntax Score >32 (OR 3.53, P=0.012), ACS as the indication (OR 3.24, P=0.012), peripheral artery disease (OR 2.20, P=0.042), and age >75 years (OR 2.09, P=0.05). CONCLUSIONS: Our experience showed acceptable results of UPLM PCI in STEMI patients, where short-term prognosis was related to hemodynamic conditions, good results in NSTEMI/UA patients where mortality increased in the follow-up due to comorbidities, and very good results in patients with stable CAD.

Validation of predictors of intraprocedural stent thrombosis in the drug-eluting stent era.

Although predictors of acute intraprocedural stent thrombosis (IPST) in the drug-eluting stent era have been proposed, external validation is lacking. We thus analyzed the occurrence of IPST in the RECIPE study and found that, among 1,320 patients who underwent drug-eluting stent implantation, IPST occurred in 6 (0.5%), with in-hospital major adverse events in 4 (67%). IPST was predicted by number and total length of implanted stents, baseline minimal lumen diameter, and, in a pooled analysis that incorporated values from the present study and a previous study, use of elective glycoprotein IIb/IIIa inhibitors. Such results may provide useful information to guide prevention of this complication.

Detection and assessment of coronary artery anomalies by three-dimensional magnetic resonance coronary angiography.

BACKGROUND: Coronary artery anomalies (CAAs) are a relatively rare condition usually diagnosed in vivo by conventional angiography. In the past few years Magnetic resonance coronary angiography (MRCA) has been used to detect CAAs and found to be highly accurate. No data is available regarding the ability of MRCA to detect previously not suspected anomalies. METHODS: We prospectively analyzed the origin and course of 336 patients undergoing a diagnostic Cardiovascular magnetic resonance (CMR) study. After the completion of a standard examination a navigator-echo 3D-MRCA low-quality scan was used in all the cases to rule out CAAs. The high-quality MRCA was applied only if an abnormal coronary arterial tree was seen. RESULTS: Nineteen patients with CAAs (12 men, 7 women; mean age, 53+/-18 years) were identified by MRCA. Six out of the 19 CAAs subjects had already been detected by other means (coronary angiography in 5, and transesophageal echocardiography in 1 case). However in none of them a complete anatomical assessment was achieved. In 13 patients CAAs were an unexpected and new finding. MRCA was able to assess the origin and proximal course of the anomalous artery in all the cases. CONCLUSIONS: MRCA is able to detect the presence and anomalous course of CAAs. Besides offering precise information about already suspected CAAs, MRCA can identify anomalies previously not suspected. This study suggests a potential role for MRCA as a screening tool for CAAs in young patients with angina, ventricular arrhythmias, or unexplained syncope as well as in highly competitive athletes.

The incidence and timing of major arrhythmias following successful primary angioplasty for acute myocardial infarction.

BACKGROUND: The potential benefits of direct percutaneous transluminal coronary angioplasty (PTCA) on malignant arrhythmias in the hospital phase of acute myocardial infarction have not yet been established. METHODS: We prospectively investigated the incidence and timing of major arrhythmias occurring during direct PTCA and within 24 hours of mechanical reperfusion in 90 consecutive patients with acute myocardial infarction undergoing successful direct PTCA within 12 hours of symptom onset. RESULTS: Ventricular fibrillation and complete atrioventricular block occurred exclusively during direct PTCA and both resolved in the catheterization laboratory. Holter monitoring showed that ventricular tachyarrhythmias, such as runs of more than 3 extrasystoles, were detectable only during the first 8 hours after direct PTCA. CONCLUSIONS: In our group of patients undergoing successful direct PTCA, no in-hospital life-threatening arrhythmias occurred after this procedure.

Anabolic androgenic steroid-induced Takotsubo cardiomyopathy.

Anabolic steroid abuse, aimed at increasing muscle mass, has been growing in recent years. We describe a case of a 25-year-old bodybuilder who, after taking nandrolone and stanozolol, presented with Takotsubo syndrome. The angiography showed a normal coronary anatomy with the absence of stenosis. The left ventricular function was completely normalised after 1 week.

Age-related changes in treatment strategies for acute myocardial infarction: a population-based study.

OBJECTIVES: To compare across four age groups (<65, 65-74, 75-84, > or =85) the determinants of coronary reperfusion therapy (CRT) use in ST-segment elevation acute myocardial infarction (STE-AMI). DESIGN: Population-based, observational study. SETTING: Performed in the health district of Florence, Italy, where percutaneous coronary intervention (PCI) is the preferred CRT. PARTICIPANTS: Nine hundred thirty patients with STE-AMI prospectively enrolled in the Florence AMI registry. MEASUREMENTS: Use of CRT, clinical factors associated with CRT use. RESULTS: CRT use was reduced from 71% at younger than 65 to 31% at aged 85 and older (P<.001). After adjusting for chronic comorbidity, Killip class, admission hospital category, hospitalization delay, and AMI location, CRT use was 29% (P=.17) lower at age 75 to 84 and 63% (P<.001) lower at age 85 and older than at younger than 65. Within each age group, the probability of receiving CRT was three to five times greater in patients directly admitted to the hospital with PCI facilities. Acute cardiac failure and chronic comorbidity were associated with lower CRT use only in patients aged 65 and older. Patients aged less than 85 years who received reperfusive therapy had a significantly lower risk of death (-44%, P=.045) at 1 year, whereas it was less evident and nonsignificant (-27%, P=.27) in patients aged 85 and older. CONCLUSION: Results confirm that, although they might substantially benefit from CRT during STE-AMI, older patients are excluded from CRT even when eligible. This further indicates that clinicians are not yet completely prepared to manage most efficiently frail elderly with AMI, a task requiring a specific interdisciplinary training program in geriatric cardiology.