One-year mortality in patients with acute ST-elevation myocardial infarction in the Vienna STEMI registry.

BACKGROUND AND AIM: Systems of care to treat acute ST-elevation myocardial infarction (STEMI) have been developed world wide in the past decade. Their effectiveness can only be proven by including and analyzing outcome data of consecutive patients in registries, which is not the case in the majority of STEMI networks. This study investigates 1-year mortality in STEMI patients in Vienna included over a 14 months time interval. The Vienna STEMI network is organized by a specific rotational system and offers both, primary percutaneous intervention (PPCI) and thrombolytic therapy (TT) as reperfusion strategies according to the recent guidelines. METHODS: At the time of investigation, the Vienna STEMI network consisted of the Viennese Ambulance Systems and five high-volume interventional cardiology departments. This network has been organized in order to increase the number of STEMI patients admitted for PPCI and to offer the fastest available reperfusion strategy, in the majority PPCI but in selected patients also TT (STEMI of short duration, mainly anterior wall MI and mainly patients younger than 75 years), followed by rescue PCI in non-responders and elective angiography with/without PCI in responders to TT during the index hospital stay. RESULTS: One-year all-cause mortality rates in the Vienna STEMI network by use of the fastest available reperfusion strategy were 13.4% in patients who received reperfusion therapy after 2 h of symptom onset and 7.4% in patients treated within 2 h; (p = 0.017). Whereas PPCI and TT demonstrated a nonsignificant difference in 1-year mortality rates when initiated within 2 h of symptom onset (10.0% vs 5.7%; p = 0.59), PPCI was more effective in acute STEMI of > 2 h duration as compared to TT but this difference did not reach statistical significance (12.1% vs 18.2%; p = 0.07). CONCLUSIONS: The reassuring long-term results of the Viennese STEMI network are another example of a specific regional system of care to offer timely diagnosis, transfer and reperfusion in patients with STEMI. In contrast to other metropolitan areas where TT has almost completely abandoned, we still use pharmacological reperfusion as a backup in case of expected and unacceptable time delays for PPCI in order to reduce myocardial damage especially in patients with larger infarctions of short duration with a low risk of bleeding complications.

Coronary subclavian steal syndrome: an extracoronary cause of acute coronary syndrome.

Significant atherosclerotic changes of the coronary arteries are the common cause of cardiac chest pain. We report the case of an 80-year-old woman suffering from unstable angina caused by extracoronary atherosclerosis. The patient had an extensive medical history with severe coronary heart disease and cardiac bypass surgery (LIMA to LAD, two venous bypass grafts). An urgent coronary angiography was performed. The angiogram displayed the already known three-vessel disease, the bypass grafts were in a good functional condition. Subsequently, a stenosis of the proximal segment of the left subclavian artery was detected. Measurement of the pullback pressure gradient confirmed the significance of the stenosis. We suspected a "steal phenomenon" concerning the bypass graft LIMA to LAD. An ad hoc PTA with consecutive stenting (self-expandable stent) enabled a successful revascularization of the left subclavian artery without any adverse effects to the vertebral arteries. Cardiac chest pain did not occur any more. Coronary Subclavian Steal Syndrome should be considered a rare but important differential diagnosis in acute coronary syndrome after bypass surgery.

Comparison of short- and long-term results of drug-eluting vs. bare metal stenting in the porcine internal carotid artery.

PURPOSE: To evaluate the development of neointimal hyperplasia after implantation of drug-eluting stents (paclitaxel) compared to bare metal stents in porcine internal carotid arteries (ICAs). METHODS: While drug-eluting stents have effectively reduced neointimal proliferation in porcine external carotid arteries, the porcine internal carotid artery (ICA) is more sensitive to shear stress and altered flow conditions. Thus, a study was conducted to evaluate bare vs. drug-eluting stents in porcine ICAs. Under general anesthesia, 18 domestic pigs were implanted with paclitaxel-eluting (n = 18) and bare (n = 18) stents in the left and right ICAs, respectively. After 1 and 3 months, control carotid angiography was performed, followed by histopathological and histomorphometric analyses of the stented ICA. RESULTS: Histopathological results (fibrin deposition, necrosis, inflammation) were similar in the groups at 1 and 3 months. Moreover, the injury score and rate of endothelialization did not differ between the groups. Histomorphometric analysis after 1 month revealed significantly (p<0.05) less neointimal hyperplasia after implantation of paclitaxel-eluting stents. The antiproliferative effect of paclitaxel-eluting stents were maintained during the 3-month follow-up: the neointimal area was 0.7 ± 0.5 vs. 1.2 ± 0.6 mm(2) (p<0.01), the area stenosis was 23.5% ± 13.9% vs. 37.8% ± 14.4% (p<0.01), the maximal neointimal thickness was 0.2 ± 0.1 vs. 0.2 ± 0.9 mm (p<0.05) in paclitaxel-eluting vs. bare stents, respectively. Implantation of paclitaxel-eluting and bare stents did not lead to edge restenosis or vessel remodeling in porcine ICAs at 1 or 3 months. CONCLUSION: Compared to bare metal stents, drug-eluting stents implanted in the porcine ICA produced significantly less neointimal hyperplasia.

2-year results of the AUTAX (Austrian Multivessel TAXUS-Stent) registry beyond the SYNTAX (synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) study.

OBJECTIVES: The multicenter AUTAX (Austrian Multivessel TAXUS-Stent) registry investigated the 2-year clinical/angiographic outcomes of patients with multivessel coronary artery disease after implantation of TAXUS Express stents (Boston Scientific, Natick, Massachusetts), in a "real-world" setting. BACKGROUND: The AUTAX registry included patients with 2- or 3-vessel disease, with/without previous percutaneous coronary intervention (PCI) and concomitant surgery. METHODS: Patients (n = 441, 64 +/- 12 years, 78% men) (n = 1,080 lesions) with possible complete revascularization by PCI were prospectively included. Median clinical follow-up was 753 (quartiles 728 to 775) days after PCI in 95.7%, with control angiography of 78% at 6 months. The primary end point was the composite of major adverse cardiac (nonfatal acute myocardial infarction [AMI], all-cause mortality, target lesion revascularization [TLR]) and cerebrovascular events (MACCE). Potential risk factor effects on 2-year MACCE were evaluated using Cox regression. RESULTS: Complete revascularization was successful in 90.5%, with left main PCI of 6.8%. Rates of acute, subacute, and late stent thrombosis were 0.7%, 0.5%, and 0.5%. Two-year follow-up identified AMI (1.4%), death (3.6%), stroke (0.2%), and TLR (13.1%), for a composite MACCE of 18.3%. The binary restenosis rate was 10.8%. The median of cumulative SYNTAX score was 23.0 (range 12.0 to 56.5). The SYNTAX score did not predict TLR or MACCE, due to lack of scoring of restenotic or bypass stenoses (29.8%). Age (hazard ratio [HR]: 1.03, p = 0.019) and acute coronary syndrome (HR: 2.1, p = 0.001) were significant predictors of 2-year MACCE. Incomplete revascularization predicted death or AMI (HR: 3.84, p = 0.002). CONCLUSIONS: With the aim of complete revascularization, TAXUS stent implantations can be safe for patients with multivessel disease. The AUTAX registry including patients with post-PCI lesions provides additional information to the SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) study. (Austrian Multivessel TAXUS-Stent Registry; NCT00738686).

Gender-related outcome following percutaneous coronary intervention for ST-elevation myocardial infarction: data from the Austrian acute PCI registry.

AIMS: Whether or not primary percutaneous coronary intervention (P-PCI) is equally effective and safe in women and men in a real world setting is still a matter of debate. The aim of this study was to evaluate the effect of gender on in-hospital outcome after P-PCI for ST-elevation myocardial infarction (STEMI) in a prospective national registry. METHODS AND RESULTS: This registry includes in-hospital outcome data from 19 PCI-performing hospitals. During 12 months, 1087 patients with STEMI were registered (mean age 62 +/- 13 years; 27% women). Women were older than men (67 +/- 13 vs. 60 +/- 13 years; p < 0.001) and more often had diabetes mellitus (21% vs. 13%; p < 0.001) or cardiogenic shock (15% vs. 9%; p=0.004). PCI was performed in 1004 patients (92.4%) and more frequently in men than in women (93.9 vs. 88.3%, p=0.002), whereas conservative treatment was more often decided in women (9.3% vs 4.3%; p=0.002). No differences were found between women and men in primary success rate (TIMI 2+3 flow, 92.9% vs. 93%; p=0.96). On univariate analysis, in-hospital mortality was higher in women than in men (13.7% vs. 7.2%; p=0.001). On multivariable analysis age, shock, diabetes and TIMI flow before PCI remained associated with mortality. CONCLUSIONS: Women have higher in-hospital mortality following PCI for STEMI. On multivariate analysis age, shock, diabetes and TIMI flow, but not gender, were associated with mortality in this national register. Older age and more comorbidity are likely to explain the higher mortality in female patients undergoing P-PCI.

Fracture of a drug-eluting stent in the tibioperoneal trunk following bifurcation stenting.

PURPOSE: To report a complication of stent placement at a bifurcation in the infrapopliteal arteries. CASE REPORT: A 60-year-old man presented with a complex subtotal stenosis in the anterior tibial artery and the tibioperoneal trunk. Two drug-eluting stents were implanted by means of the crush technique, successfully recanalizing the trifurcation. One week later, the patient was readmitted with a thrombotic occlusion of the popliteal artery. Fluoroscopy showed a fracture of the larger stent in the tibioperoneal trunk. After successful local thrombolysis, a stent fragment was located in the popliteal artery and removed with an Amplatz snare. Long-term follow-up was uneventful. CONCLUSION: Fracture may be a more common complication of bifurcation stenting when undertaken in a territory at high risk for this complication.

Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry).

BACKGROUND: The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area. METHODS AND RESULTS: We organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours' duration. CONCLUSIONS: Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.

Intracranial pressure monitoring and case mix-adjusted mortality in intracranial hemorrhage.

OBJECTIVE: Intracranial pressure (ICP) monitoring is frequently used in intensive care treatment of patients with intracranial hemorrhage. Data demonstrating an improved outcome from this intervention are lacking. We analyzed standardized mortality ratios in patients with and without ICP monitoring to determine its efficacy. DESIGN: A nonrandomized study of case records of consecutively admitted intensive care unit (ICU) patients with intracranial hemorrhage. SETTING: General and medical ICU of a 900-bed tertiary-care hospital. PATIENTS: A total of 225 patients with intracranial hemorrhage (mainly nontraumatic) admitted consecutively between April 1997 and March 2000. MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, diagnosis, age, sex, use of ICP monitoring, and in-hospital mortality rates were collected from the hospital's ICU database. Expected mortality was provided by means of SAPS II. Standardized mortality ratios were calculated and compared in 119 patients with ICP monitoring and 106 patients without ICP monitoring. MAIN RESULTS: The case mix-adjusted hospital mortality in the group with ICP monitoring was in the expected range (standardized mortality ratio, 1.09 [95% confidence interval (CI), 0.87-1.31]). Patients without ICP monitoring had a significantly higher standardized mortality ratio than expected (1.26 [95% CI, 1.06-1.46]). CONCLUSIONS: A beneficial effect of ICP monitoring in patients with intracranial hemorrhage may be reflected in an improved standardized mortality ratio.