Utility of fractional flow reserve to determine treatment after recent large myocardial infarction with severe left ventricular dysfunction.

Evaluation of ischemia and the extent of viable myocardium is required prior to consideration of revascularizing a lesion after a myocardial infarction in which there is hypo- or akinesis. We present a case in which we utilized fractional flow reserve (FFR) of a lesion in a patient whose nuclear study 7 days after infarction suggested minimal viability in the infarct zone. After FFR was positive, stenting was performed with recovery of a large amount of viable myocardium at 1 month as shown on nuclear study. This case illustrates that if ischemia is demonstrated by FFR in an infarct-related artery even with minimal viability by nuclear study, revascularization may result in significant myocardial recovery.

Effect of chronic angiotensin converting enzyme inhibitor therapy on myocardial injury in patients undergoing percutaneous coronary interventions.

BACKGROUND: Procedural MI is a frequent complication of percutaneous coronary intervention (PCI). Angiotensin converting enzyme inhibitors (ACE-I) have been shown to reduce ischemic events in the setting of acute myocardial infarction (MI) and heart failure. OBJECTIVE: We sought to evaluate whether chronic ACE-I treatment prior to PCI reduces the incidence of procedural MI. METHODS: The study cohort included consecutive patients from January 2003 to August 2004 undergoing PCI with normal baseline serum creatinine kinase (CK) and cardiac CK isoform (CK-MB) (n = 265). Procedural MI was defined as CK-MB elevation ≥ 3 times the upper limit of normal. RESULTS: Patients on chronic ACE-I had a higher baseline prevalence of adverse prognostic features including diabetes (p = 0.02) and a trend towards a lower incidence of drug-eluting stent use (p = 0.07). Using multiple logistic regression, patients on chronic ACE-I therapy (n = 138) had a 64% reduction in procedural MI compared with those not on ACE-I (n = 127; odds ratio = 0.36; 95% confidence intervals 0.13-0.99; p = 0.05). Long-term outcomes, including death and major adverse cardiac events (MACE) (combined total of death, MI and target lesion revascularization were similar in the two groups. Procedural MI was, however, associated with increased MACE during follow up (60% vs. 35.4%; p = 0.035). CONCLUSION: Chronic ACE-I therapy before PCI may reduce the incidence of procedural MI.

Changes in guidelines for prevention of infective endocarditis.

As there is no sufficient evidence to support the previous guidelines for antibiotic prophylaxis against IE, the AHA has restricted the number of cardiac conditions for which prophylaxis is recommended to only those that carry a greater risk for adverse outcomes. By recommending prophylaxis for almost all procedures involving incision of oral and respiratory mucosa and excluding GI and GU tract procedures, AHA has attempted to obtain a greater uniformity and consistency of antibiotic prophylaxis for IE. Physicians should understand that a greater emphasis on educating their patients about oral hygiene will reap substantial benefits compared to antibiotic prophylaxis before dental procedures.

Predictors of in-stent restenosis and patient outcome after percutaneous coronary intervention in patients with diabetes mellitus.

Diabetics have a significantly higher incidence of major adverse cardiac events (MACEs) and in-stent restenosis (ISR) than nondiabetics after percutaneous coronary intervention (PCI). Predictors of MACEs and ISR are uncertain in diabetics. In recent studies, microalbuminuria and proliferative retinopathy have been believed to relate to progressive coronary atherosclerosis. We retrospectively studied 191 consecutive patients (mean age 65 +/- 9 years) with diabetes who underwent PCI to determine predictors of ISR and MACEs (defined as cumulative incidence of myocardial infarction, revascularization, or death from cardiovascular cause), with special reference to microalbuminuria and proliferative retinopathy. Of 191 patients, 106 (56%) had a follow-up coronary angiogram at 16 +/- 2 months. Of these 106 patients, 66 (62%) developed ISR. In the multivariate model, microalbuminuria or proliferative retinopathy did not achieve significant association with ISR. Serum high-density lipoprotein cholesterol levels were significantly associated with a lower incidence of ISR (odds ratio [OR] 0.928, 95% confidence interval [CI] 0.876 to 0.983, p = 0.011) and MACEs (OR 0.96, 95% CI 0.931 to 1.000, p = 0.048). Use of drug-eluting stents also had a negative association with ISR (OR 0.171, 95% CI 0.05 to 0.585, p = 0.004). Renal insufficiency was associated with higher MACEs (OR 3.19, 95% CI 1.45 to 7.031, p = 0.0039). In conclusion, serum high-density lipoprotein cholesterol levels were inversely associated with ISR or MACEs.