Effect of Nitroglycerin on the Performance of MR Coronary Angiography.

PURPOSE: To systematically investigate the effect of sublingual glyceryl trinitrate (nitroglycerin=nitro=glyceryl trinitrate=GTN=C3 H5 N3 O9 [NTG]) on the diagnostic performance of MR coronary artery imaging (MRCA) to detect relevant coronary artery disease (CAD). MATERIALS AND METHODS: Thirty-five healthy volunteers and 25 patients with suspected or proven CAD (all in sinus rhythm) underwent MRCA before and after NTG using a contrast-agent free, three-dimensional, navigator-based, steady state free precession acquisition (voxel size 1.0 × 0.7 × 0.7 mm3 ) at 1.5 Tesla. Target parameters were stenosis detection (>50%), visible vessel length (straightened planar reconstruction) and vessel diameter (curved planar reconstruction, measured proximal/medial/distal). In patients, invasive coronary angiography served as reference. RESULTS: NTG led to increase of the coronary diameter both in healthy volunteers (right coronary artery [RCA]: 3.2 to 3.7 mm, P < 0.001; left anterior descending coronary artery [LAD]: 2.9 to 3.4 mm, P = 0.009; left circumflex coronary artery [LCx]: 2.8 to 3.3 mm, P < 0.001) and patients (RCA 3.5 to 4.0 mm, P = 0.01; LAD 3.3 to 3.7 mm, P = 0.008; LCx: 2.9 to 3.3 mm, P = 0.03). Visible vessel length increased after NTG for the LAD (volunteers: 72 to 84 mm, P = 0.03; patients: 56 to 78 mm, P = 0.01) and for LCx (volunteers: 48 to 60 mm, P = 0.02). Sensitivity to detect > 50% stenosis improved after NTG from 88.0 to 96%, specificity from 46.5 to 69.8%, diagnostic accuracy from 61.8 to 79.4% and positive/negative predictive value from 48.9 to 64.9% and 87.0 to 96.8%, respectively. CONCLUSION: Sublingual administration of NTG significantly enhanced the visibility of the coronary arteries and improved the detection of coronary artery stenosis. LEVEL OF EVIDENCE: 2 J. MAGN. RESON. IMAGING 2017;45:1419-1428.

Influence of prior myocardial infarction on outcome in patients with ischaemic HFrEF: insights from the EVIdence based TreAtment in Heart Failure (EVITA-HF) registry.

BACKGROUND: There is scarce information about the influence of prior myocardial infarction (pMI) on outcomes in patients (pts) with ischaemic HFrEF. We analysed data from the EVIdence based TreAtment in Heart Failure (EVITA-HF) registry. METHODS: EVITA-HF comprises web-based case report data on demography, diagnostic measures, adverse events and 1-year follow-up of patients hospitalized for chronic heart failure ≥ 3 months (CHF) and an ejection fraction ≤ 40%. In the present study, we focused on the outcomes of pts with and without pMI in ischaemic HFrEF. RESULTS: Between February 2009 and November 2015, a total of 2075 consecutive pts with ischaemic HFrEF were included from 16 centres in Germany. A total of 81.2% were male, and the mean age was 71 years. A total of 61.5% of the pts with ischaemic HFrEF had a history of pMI. These pts were treated less often with PCI (20.0 vs. 31.0%, p < 0.001) or CABG (3.8 vs. 7.7%, p < 0.001). They more often received an ICD (40.9 vs. 28.7%, p < 0.001), but less often a CRT-D (11.3 vs. 19.4%, p < 0.001). After multivariate adjustment, pts with pMI had a greater all-cause mortality after 1 year than those without pMI (hazard ratio 1.4; 95% CI, 1.10-1.79, p = 0.007). The combined endpoint of death, resuscitation or ICD shock after 1 year was greater in patients with pMI (20.8 vs. 16.4%, p = 0.03). Mobility was more often reduced in pts with pMI (46.8% vs. 40.1%, p = 0.03), and overall health status was more frequently worse in patients with pMI than in those 12 months ago (23.1 vs. 15.9%, p = 0.01). More than a quarter of the pts with ischaemic HFrEF were anxious or depressive. CONCLUSION: pMI in patients with CHF and ischaemic HFrEF was associated with increased mortality, increased event rates, and worsened health status. Hence, the subgroup of pts with ischaemic HFrEF and pMI is at higher risk and deserves special attention.

Current spectrum and outcomes of infarct-related cardiogenic shock: insights from the CULPRIT-SHOCK registry and randomized controlled trial.

AIMS: We analysed consecutive patients with acute myocardial infarction complicated by cardiogenic shock (CS) who were enrolled into the CULPRIT-SHOCK randomized controlled trial (RCT) and those with exclusion criteria who were included into the accompanying registry. METHODS AND RESULTS: In total, 1075 patients with infarct-related CS were screened for CULPRIT-SHOCK in 83 specialized centres in Europe; 369 of them had exclusion criteria for the RCT and were enrolled into the registry. Patients were followed over 1 year. The mean age was 68 years and 260 (25%) were women. 13.5%, 30.9%, and 55.6% had one-vessel, two-vessel, and three-vessel coronary artery disease (CAD), respectively. Significant left main (LM) coronary artery stenosis was present in 8.0%. 54.2% of the patients had cardiac arrest before admission. Thrombolysis in myocardial infarction (TIMI) 3 patency of the infarct vessel after percutaneous coronary intervention was achieved in 83.6% of all patients. Mechanical circulatory support was applied in one-third of patients. Total mortality after 30 days and 1 year was 47.6% and 52.9%. Mortality after 1 year was highest in patients with LM coronary artery stenosis (63.5%), followed by three-vessel (56.6%), two-vessel (49.8%), and one-vessel CAD (38.6%), respectively. Mechanical complications were rare (21/1008; 2.1%) but associated with a high mortality of 66.7% after 1 year. CONCLUSION: In specialized centres in Europe, short- and long-term mortality of patients with infarct-related CS treated with an invasive strategy is still high and mainly depends on the extent of CAD. Therefore, there is still a need for improvement of care to improve the prognosis of infarct-related CS.

Diagnostic performance of non-contrast-enhanced whole-heart magnetic resonance coronary angiography in combination with adenosine stress perfusion cardiac magnetic resonance imaging.

BACKGROUND: We sought to evaluate the diagnostic performance of 1.5-T non-contrast enhanced whole-heart magnetic resonance coronary angiography (MRCA) alone and in combination with adenosine stress cardiac magnetic resonance imaging (CMR-Perf). MRCA has been proposed to allow for detection of coronary artery disease (CAD). Yet, recent studies failed to show an incremental value of MRCA when added to CMR-Perf. METHODS: Non-Gadolinium 1.5-T contrast-enhanced, electrocardiogram-triggered, navigator-gated free-breathing MRCA was performed in 144 patients (pts) with suspected or known CAD. Accuracy of MRCA in detecting CAD was evaluated using X-ray coronary angiography as the reference. A novel algorithm was used to combine the results of MRCA and CMR-Perf. RESULTS: MRCA was diagnostic in 96/144 pts (67%) with regular breathing (mean age 62.5 ± 13); 77% of all coronary segments (939/1226) and 92% of segments suitable for percutaneous coronary intervention (792/866) were assessable. In 59 pts a novel algorithm to combine MRCA and CMR-Perf was performed with high diagnostic performance: accuracy, sensitivity, specificity, negative and positive predictive values were 91.5% (54/59; 95% CI, 84%-99%), 95.7% (22/23; 77-100), 88.9% (32/36; 74-96), 84.6% (22/26; 71-99), and 97.0% (32/33; 91-100). Compared to the combined use of CMR-Perf and late gadolinium enhancement, specificity with the novel algorithm significantly increased (P = .008). CONCLUSION: MRCA has a high assessability in segments suitable for percutaneous coronary intervention in pts with regular breathing. The combined use of MRCA and CMR-Perf improved specificity for the detection of significant CAD.

Prognostic impact of secondary prevention after coronary artery bypass grafting-insights from the TiCAB trial.

OBJECTIVES: There are disparities in the adherence to guideline-recommended therapies after coronary artery bypass graft (CABG). We therefore sought to evaluate the effect of guideline-adherent medical secondary prevention on 1-year outcome after CABG. METHODS: Data were taken from the randomized 'Ticagrelor in CABG' trial. From April 2013 until April 2017, patients who underwent CABG were included. For the present analysis, we compared patients who were treated with optimal medical secondary prevention with those where 1 or more of the recommended medications were missing. RESULTS: Follow-up data at 12 months were available in 1807 patients. About half (54%) of them were treated with optimal secondary prevention. All-cause mortality [0.5% vs 3.5%, hazard ratio (HR) 0.14 (0.05-0.37), P < 0.01], cardiovascular mortality [0.1% vs 1.7%, HR 0.06 (0.01-0.46), P = 0.007] and major adverse events [6.5% vs 11.5%, HR 0.54 (0.39-0.74), P < 0.01] were significantly lower in the group with optimal secondary prevention. The multivariable model for the primary end point based on binary concordance to guideline recommended therapy identified 3 independent factors: adherence to guideline recommended therapy [HR 0.55 (0.39-0.78), P < 0.001]; normal renal function [HR 0.99 (0.98-0.99), P = 0.040]; and off-pump surgery [HR 2.06 (1.02-4.18), P = 0.045]. CONCLUSIONS: Only every second patient receives optimal secondary prevention after CABG. Guideline adherent secondary prevention therapy is associated with lower mid-term mortality and less adverse cardiovascular events after 12 months.

Negative predictive value of normal adenosine-stress cardiac MRI in the assessment of coronary artery disease and correlation with semiquantitative perfusion analysis.

PURPOSE: To prospectively determine the negative predictive value of normal adenosine stress cardiac MR (CMR) in routine patients referred for evaluation of coronary artery disease (CAD), predominantly with intermediate to high pretest risk. MATERIALS AND METHODS: Consecutive patients referred for coronary angiography were examined in a 1.5 Tesla whole-body scanner before catheterization. A total of 158 patients with normal CMR on qualitative assessment were included, and semiquantitative perfusion analysis was performed. Significant CAD was regarded as luminal narrowing of >or=70% in coronary angiography. RESULTS: In the 158 study patients, negative predictive value of normal adenosine-stress CMR for significant CAD was 96.2% (for stenosis >or=90%: 98.1%). True-negative and false-negative patients were comparable regarding clinical presentation, risk factors, and CMR findings. Semiquantitative perfusion analysis gave significantly prolonged arrival time index and peak time index in the false-negative group. Using cutoff values >1.8 for arrival time index or >1.2 for peak time index, the CMR negative predictive value increased to 98.7% (for stenosis >or=90%: to 100%). CONCLUSION: The very high negative predictive value for CAD supports CMR-based decision making for the indication to coronary angiography. Semiquantitative perfusion analysis seems promising to identify the small group of CAD patients not detectable by qualitative CMR assessment.

Efficacy and safety of optimized antithrombotic therapy with aspirin, clopidogrel and enoxaparin in patients with non-ST segment elevation acute coronary syndromes in clinical practice.

In randomized clinical trials enoxaparin in non ST-elevation acute coronary syndromes (NSTE-ACS) has been shown to be more effective than unfractionated heparin in preventing the combined endpoint of death and myocardial infarction. Clopidogrel in combination with aspirin reduced the combined endpoint of death, myocardial infarction and stroke in NSTE-ACS patients compared to aspirin alone. Aim of the present study was to determine the clinical impact of optimized antithrombotic therapy with enoxaparin, clopidogrel and aspirin compared to standard therapy with unfractionated heparin (UFH) and aspirin in NSTE-ACS in clinical practice. We analyzed data of 2,956 consecutive patients with NSTE-ACS and either antithrombotic therapy with enoxaparin, clopidogrel and aspirin or with aspirin and UFH, which were prospectively enrolled in the acute coronary syndromes registry (ACOS) from July 2000 until the end of November 2002. After adjustment for baseline characteristics and PCI the combined endpoint of hospital death and non-fatal reinfarctions was lower in the group with optimized antithrombotic therapy including clopidogrel, enoxaparin and aspirin compared to the control-group with aspirin and UFH (odds ratio 0.30, 95% confidence interval 0.16-0.53). There was no significant difference in major bleedings between the two treatment groups (1.5% vs. 0.9%, P = 0.35), while overall there were more bleeding complications in the group with optimized antithrombotic therapy (4.9% vs. 2.0%, P = 0.005). In clinical practice optimized antithrombotic therapy with aspirin, clopidogrel and enoxaparin in NSTE-ACS is associated with a reduction in the combined endpoint of death and non-fatal reinfarctions compared to standard therapy with aspirin and UFH without increase in major bleeding complications.

Efficacy and safety of enoxaparin in unselected patients with ST-segment elevation myocardial infarction.

In randomized clinical trials the low-molecular-weight heparin enoxaparin has been shown to reduce ischemic complications in patients with acute ST elevation myocardial infarction (STEMI) treated with fibrinolysis. Little is known about the use and efficacy of enoxaparin in unselected patients with STEMI in clinical practice. In a retrospective analysis of the prospective ACOS registry we compared the outcomes of patients with STEMI treated with enoxaparin or unfractionated heparin. A total of 6,299 patients with STEMI < 12 hours were included in this analysis, 609 (10%) were treated with enoxaparin and 5,690 (90%) with unfractionated heparin. In the multivariable propensity score analysis enoxaparin was associated with a reduction in the combined endpoint of death and non-fatal reinfarction in the entire group (odds ratio 0.59; 95% CI 0.43-0.80) and the subgroups of patients treated without early reperfusion (odds ratio 0.65, 95% CI 0.43-0.97), fibrinolysis (odds ratio 0.64; 95% CI 0.33-1.26) and primary percutaneous coronary intervention (odds ratio 0.33; 95% CI 0.15-0.72). There was no significant increase in severe bleeding complications with enoxaparin (6.5% versus 5.5%, p = 0.4). In clinical practice in unselected patients with STEMI treated with or without early reperfusion therapy early treatment with enoxaparin compared to unfractionated heparin is associated with a significant reduction of the combined endpoint of inhospital death and reinfarction without a significant increase in severe bleeding complications.

Clopidogrel in addition to aspirin reduces in-hospital major cardiac and cerebrovascular events in unselected patients with acute ST segment elevation myocardial.

We sought to assess the effect of clopidogrel on in-hospital events in unselected patients with acute ST elevation myocardial infarction (STEMI). In a retrospective analysis of consecutive patients enrolled in the Acute Coronary Syndromes (ACOS) registry with acute STEMI we compared outcomes of either adjunctive therapy with aspirin alone or aspirin plus clopidogrel within 24 hours after admission.A total of 7,559 patients were included in this analysis, of whom 3,541 were treated with aspirin alone, and 4,018 with dual antiplatelet therapy. The multivariable analysis with adjustment for baseline characteristics and treatments showed that the rate of in-hospital MACCE (death, non-fatal reinfarction, non-fatal stroke) was significantly lower in the aspirin plus clopidogrel group,compared to the aspirin alone group in the entire cohort and all three reperfusion strategy groups (entire group odds ratio 0.60, 95% CI 0.49-0.72 , no reperfusion OR 0.69,95% CI 0.51-0.94,fibrinolysis OR 0.62,95% CI 0.44-0.88, primary PCI OR 0.54, 95% CI 0.39-0.74). There was a significant increase in major bleeding complications with clopidogrel (7.1% vs. 3.4%, p<0.001). In clinical practice early adjunctive therapy with clopidogrel in addition to aspirin in patients with STEMI is associated with a significant reduction of in-hospital MACCE regardless of the initial reperfusion strategy. This advantage was associated with an increase in major bleeding complications.

[Temporal trends in the use of drug-eluting stents in German clinical practice]. / Trends im Einsatz von Drug-eluting Stents im klinischen Alltag in Deutschland. Daten des ALKK-Registers.

BACKGROUND AND PURPOSE: : Drug-eluting stents (DES) have been shown to reduce the risk of in-stent stenosis, one of the major problems of percutaneous coronary intervention (PCI) with implantation of baremetal stents. DES are approved in Germany since 2002. The following study is based on data of the ALKK PCI registry and assesses the use of DES depending on patient characteristics, indication and coronary status comparing the treatment years 2003 and 2005. METHODS: : The ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte) PCI registry is focused on quality management based on guidelines in coronary interventions. Data were obtained by standardized questionnaires and analyzed centrally at the KL-Neuhaus Datenzentrum, Ludwigshafen, Germany. For this study, data of 40,434 PCI procedures of 32 hospitals were obtained. RESULTS: : In 2003, a total of 18,564 PCIs, and in 2005, a total of 21,870 PCIs were registered. Figure 1 shows the rate of DES in PCI in the hospitals participating in the registry in both years, 2003 and 2005. The use of DES was low with 4.3% in 2003 and increased to 19.1% in 2005. DES were mostly used in patients with stable angina (2003: 68.4%, 2005: 55.3%), in patients with former PCI (2003: 42.5%, 2005: 48.1%) and a positive stress test (DES 2003: 58.4%, 2005: 32.0%; Table 1). The rate of DES was high in unprotected left main procedures (DES 2003: 15.6%, 2005: 35.9%), PCI of ostial lesions (DES 2003: 6.4%, 2005: 32.7%), in in-stent stenosis (DES 2003: 9.5%, 2005: 40.6%), and in multivessel PCI (DES 2003: 7.6%, 2005: 29.3%; Figure 3). CONCLUSION: : DES were mainly applied in a stable situation (Figure 2), but were also increasingly used for complex coronary interventions in off-label indications.

Prognostic impact of acute beta-blocker therapy on top of aspirin and angiotensin-converting enzyme inhibitor therapy in consecutive patients with ST-elevation acute myocardial infarction.

The prognostic effect of beta-blocker treatment on ST-elevation acute myocardial infarction (STEMI) is controversially discussed in the era of reperfusion therapy. From the German multicenter registry Maximal Individual Therapy of Acute Myocardial Infarction PLUS (MITRA PLUS), 17,809 consecutive patients with STEMI treated with a guideline-recommended therapy with aspirin and an angiotensin-converting enzyme inhibitor were investigated; the prognostic effect of additional acute beta-blocker treatment was analyzed. Patients with cardiogenic shock were excluded. Of included patients, 77.6% received additional acute beta-blocker treatment and 22.4% did not. Patients with beta-blocker treatment were younger and more often received reperfusion therapy. Acute beta-blocker treatment was associated with a lower hospital mortality (univariate analysis 4.9% vs 10.8%, p <0.001; multivariate analysis odds ratio [OR] 0.70, 95% confidence interval [CI] 0.61 to 0.81). Acute beta blockade was significantly associated with a lower hospital mortality in patients without (OR 0.66, 95% CI 0.56 to 0.79) and with (OR 0.76, 95% CI 0.60 to 0.98) reperfusion therapy. The greatest benefit of acute beta-blocker treatment, measured by the number needed to treat to save 1 life, was found in patients with anterior MI, a heart rate > or =80 beats/min, no reperfusion therapy, female gender, and age > or =65 years. In conclusion, acute beta-blocker therapy in the clinical practice of treating patients with STEMI, in addition to aspirin and angiotensin-converting enzyme inhibitor therapy, was independently associated with a significant decrease in hospital mortality in patients with and without reperfusion therapy. High-risk patients with STEMI, such as elderly patients and patients without reperfusion therapy, showed a greater benefit of acute beta-blocker therapy than low-risk patients with STEMI.

Sex Differences in Percutaneous Coronary Intervention-Insights From the Coronary Angiography and PCI Registry of the German Society of Cardiology.

BACKGROUND: Several studies have suggested sex-related differences in diagnostic and invasive therapeutic coronary procedures. METHODS AND RESULTS: Data from consecutive patients who were enrolled in the Coronary Angiography and PCI Registry of the German Society of Cardiology were analyzed. We aimed to compare sex-related differences in in-hospital outcomes of patients undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease, non-ST elevation acute coronary syndromes, ST elevation myocardial infarction, and cardiogenic shock. From 2007 until the end of 2009 data from 185 312 PCIs were prospectively registered: 27.9% of the PCIs were performed in women. Primary PCI success rate was identical between the sexes (94%). There were no sex-related differences in hospital mortality among patients undergoing PCI for stable coronary artery disease, non-ST elevation acute coronary syndromes, or cardiogenic shock except among ST elevation myocardial infarction patients. Compared to men, women undergoing primary PCI for ST elevation myocardial infarction have a higher risk of in-hospital death, age-adjusted odds ratio (1.19, 95% CI 1.06-1.33), and risk of ischemic cardiac and cerebrovascular events (death, myocardial infarction, transient ischemic attack/stroke), (age-adjusted odds ratio 1.19, 95% CI 1.16-1.29). Furthermore, access-related complications were twice as high in women, irrespective of the indication. CONCLUSIONS: Despite identical technical success rates of PCI between the 2 sexes, women with PCI for ST elevation myocardial infarction have a 20% higher age-adjusted risk of death and of ischemic cardiac and cerebrovascular events. Further research is needed to determine the reasons for these differences.

Gender differences in acute non-ST-segment elevation myocardial infarction.

To assess gender-based differences in presentation and outcome after non-ST-elevation myocardial infarction (NSTEMI) in clinical practice, this study examined data from the Acute Coronary Syndrome registry, which enrolled 16,817 patients from 2000 through the end of 2002, 6,358 of them with NSTEMIs (34.1% women). Women with NSTEMIs were 7.5 years older, had a history of myocardial infarction and percutaneous coronary intervention or coronary artery bypass graft less often, and were less likely to have smoked. They more often had a history of systemic hypertension and diabetes mellitus, but this difference was due to their older age. Reperfusion therapy was performed less often in women, which still was significant after adjustment for baseline variables (odds ratio 0.71, 95% confidence interval 0.63 to 0.80). Clopidogrel was given less often in women (43.4% vs 56%). After adjustment for age, gender differences in medical therapy with statins, aspirin, and beta blockers were not significant. Hospital mortality was 1.7 times greater in women. This difference was not significant after adjustment for age (odds ratio 1.07, 95% confidence interval 0.84 to 1.35). Women had greater crude long-term mortality, but after age adjustment, this difference was no longer significant (odds ratio 0.92, 95% confidence interval 0.76 to 1.11). In conclusion, women with NSTEMIs were older than men and thus more often had concomitant diseases but less often had a history of myocardial infarction or coronary artery bypass grafts. They less often received acute percutaneous coronary intervention and less often were treated with clopidogrel. However, there was no difference in age-adjusted mortality in women.

Gender differences in therapeutic recommendation after diagnostic coronary angiography: insights from the Coronary Angiography and PCI Registry of the German Society of Cardiology.

BACKGROUND: There is information suggesting differences and underuse of invasive coronary diagnostic and therapeutic procedures in women compared to men. METHODS: Data from consecutive patients (pts) which were enrolled in the Coronary Angiography and PCI Registry of the German Society of Cardiology were analyzed. We compared gender-related differences in diagnosis and therapeutic recommendation of pts undergoing coronary angiography (XA) for stable coronary artery disease (CAD), non-ST elevation acute coronary syndromes (NSTE-ACS) and ST elevation myocardial infarction (STEMI). RESULTS: From 2004 until the end of 2009, data of 1,060,542 invasive procedures in 1,014,996 pts were prospectively registered. One-third (34.6%) of them were female. Women less often had significant CAD, irrespective of the indication for XA. In pts with relevant CAD, percutaneous coronary interventions (PCI) were recommended in 87.1% of women versus 89.1% of men with STEMI [age-adjusted OR (aOR) 0.98, 95% CI 0.93-1.04], in 67.1 vs. 66.8% in NSTE-ACS (aOR 1.10, 1.07-1.12), and in 50.3 vs 49.4% in stable CAD (aOR 1.07, 1.05-1.09). CONCLUSIONS: In pts with significant CAD, there was no difference in recommendation for PCI between the genders in stable CAD, whereas in STEMI and NSTE-ACS women were treated even more often with PCI. There were only minor differences in referral for CABG between women and men. Hence, our data provide strong evidence against a gender bias in use of invasive therapeutic procedures once the diagnosis of significant CAD has been confirmed.

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.

Impact of ramipril versus other angiotensin-converting enzyme inhibitors on outcome of unselected patients with ST-elevation acute myocardial infarction.

We examined the impact of treatment with ramipril versus other angiotensin-converting enzyme (ACE) inhibitors on clinical outcome in unselected patients of the prospective multicenter registry Maximal Individual Therapy of Acute Myocardial Infarction PLUS registry (MITRA PLUS). Of 14,608 consecutive patients with ST-elevation acute myocardial infarction, 4.7% received acute therapy with ramipril, 39.0% received other ACE inhibitor therapy, and 56.3% received no ACE inhibitor therapy. In a multivariate analysis, the treatment with ramipril compared with the treatment without ACE inhibitors was associated with a significantly lower hospital mortality and a lower rate of nonfatal major adverse coronary and cerebrovascular events. Compared with other generic ACE inhibitors, ramipril therapy was independently associated with a significantly lower hospital mortality (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.32 to 0.90) and a lower rate of nonfatal major adverse coronary and cerebrovascular events (OR 0.65, 95% CI 0.46 to 0.93), but not with a lower rate of heart failure at discharge (OR 0.79, 95% CI 0.50 to 1.27).

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.

Comparison of clinical benefits of clopidogrel therapy in patients with acute coronary syndromes taking atorvastatin versus other statin therapies.

In clinical practice, we found no significant difference between atorvastatin therapy or other statin therapies in the clinical outcomes of patients with acute coronary syndromes receiving clopidogrel therapy. In patients receiving atorvastatin therapy, clopidogrel therapy was associated with a significant decrease in mortality and stroke during univariate analysis and a moderate trend of reduced mortality and stroke without statistical significance in the multivariate analysis.

Influence of small caliber coronary arteries on the diagnostic accuracy of adenosine stress cardiac magnetic resonance imaging.

BACKGROUND AND AIMS: Positive predictive value (PPV) of adenosine stress cardiac magnetic resonance (CMR) for coronary artery disease (CAD) is unsatisfactory. We investigated the impact of coronary caliber variability on this limitation in CMR performance. METHODS AND RESULTS: 206 consecutive patients with myocardial ischemia during CMR and subsequent coronary angiography (CA) were studied. Patients were examined in a 1.5-T scanner. After adenosine infusion, myocardial first-pass sequence using gadolinium-based contrast agent was performed and compared with rest perfusion. CAD was invasively confirmed in 165 [true positive (TP); PPV, 80.1%] and ruled out in 41 patients [false positive (FP)]. TP and FP were comparable for pre-test risk and CMR findings. We found a significant association between FP CMR and the presence of a small caliber coronary vessel (proximal diameter < one standard deviation below the mean) supplying the area of ischemia (chi-square 42.6, p < 0.0001). A small caliber artery ipsilateral to the ischemic region was a predictive parameter for FP versus TP discrimination (ROC area, 0.84 ± 0.04 vs. 0.59 ± 0.05; p < 0.0001). Further increment in diagnostic accuracy was achieved by including proximal ipsilateral/contralateral coronary diameter ratios (ROC area, 0.90 ± 0.03; p < 0.03). CONCLUSIONS: Small caliber coronary arteries found as normal variations in right-dominant or left-dominant circulation may account for hypoperfusion in the absence of coronary stenosis and thus may cause FP adenosine stress CMR results. Non-invasive assessment of proximal coronary diameters in the vessel supplying the area of ischemia could reduce FP rates, raise the diagnostic accuracy of CMR for CAD and minimize subsequent superfluous CA.

Adenosine-stress cardiac magnetic resonance imaging in suspected coronary artery disease: a net cost analysis and reimbursement implications.

The health and economic implications of new imaging technologies are increasingly relevant policy issues. Cardiac magnetic resonance imaging (CMR) is currently not or not sufficiently reimbursed in a number of countries including Germany, presumably because of a limited evidence base. It is unknown, however, whether it can be effectively used to facilitate medical decision-making and reduce costs by serving as a gatekeeper to invasive coronary angiography. We investigated whether the application of CMR in patients suspected of having coronary artery disease (CAD) reduces costs by averting referrals to cardiac catheterization. We used propensity score methods to match 218 patients from a CMR registry to a previously studied cohort in which CMR was demonstrated to reliably identify patients who were low-risk for major cardiac events. Covariates over which patients were matched included comorbidity profiles, demographics, CAD-related symptoms, and CAD risk as measured by Morise scores. We determined the proportion of patients for whom cardiac catheterization was deferred based upon CMR findings. We then calculated the economic effects of practice pattern changes using data on cardiac catheterization and CMR costs. CMR reduced the utilization of cardiac catheterization by 62.4%. Based on estimated catheterization costs of € 619, the utilization of CMR as a gatekeeper reduced per-patient costs by a mean of € 90. Savings were realized until CMR costs exceeded € 386. Cost savings were greatest for patients at low-risk for CAD, as measured by baseline Morise scores, but were present for all Morise subgroups with the exception of patients at the highest risk of CAD. CMR significantly reduces the utilization of cardiac catheterization in patients suspected of having CAD. Per-patient savings range from € 323 in patients at lowest risk of CAD to € 58 in patients at high-risk but not in the highest risk stratum. Because a negative CMR evaluation has high negative predictive value, its application as a gatekeeper to cardiac catheterization should be further explored as a treatment option.