Relation between myocardial viability and abnormalities on the signal-averaged electrocardiogram in patients with low (<40%) ejection fraction and coronary artery disease.

To determine a possible mechanism for the previously observed improved outcome after bypass surgery in patients with poor ventricular function and viable myocardium, we sought to examine the relation between the extent of viability and the frequency of an abnormal signal-averaged electrocardiogram (SAECG) in patients with reduced ejection fraction and coronary artery disease. Fifty-two patients with coronary disease and ventricular dysfunction underwent quantitative redistribution thallium-201 (Tl-201) scintigraphy at rest to determine the extent of viability. The presence of late potentials was assessed by SAECG. Long-term, cardiac event-free survival was determined. Patients with greater viability (group 1, n = 23) were similar to patients with less viability (group 2, n = 29) with respect to age, gender, ejection fraction, and incidence of arrhythmia. Fewer group 1 patients had late potentials (33% vs. 65%, p = 0.05) and individual parameters were significantly more abnormal in the group 2 patients. Patients with late potentials had less viability than patients without late potentials (viability index 0.61+/-0.15 vs. 0.69+/-0.14, respectively, p = 0.05). By multivariate analysis, only the extent of viable myocardium and the left ventricular end-diastolic pressure were independent predictors of late potentials. Survival free of cardiac death or transplantation was better in patients with a normal SAECG (p<0.04) and in patients with predominantly viable myocardium (p<0.005). Thus, patients with low ejection fraction, coronary disease, and viable myocardium have a lower frequency of late potentials, suggesting reduced susceptibility to ventricular arrhythmia.

Improved outcome after coronary bypass surgery in patients with ischemic cardiomyopathy and residual myocardial viability.

BACKGROUND: Although residual myocardial viability in patients with coronary artery disease and extensive regional asynergy is associated with improved ventricular function after coronary bypass surgery, the relationship between viability and clinical outcome after surgery is unclear. We hypothesized that patients with poor ventricular function and predominantly viable myocardium have a better outcome after bypass surgery compared with those with less viability. METHODS AND RESULTS: Seventy patients with multivessel coronary artery disease and left ventricular ejection fractions < 40% who underwent preoperative quantitative 201Tl scintigraphy before coronary bypass surgery were analyzed retrospectively. 201Tl scintigrams were reviewed blindly, and each segment was assigned a score based on defect magnitude. Segmental viability scores were summed and divided by the number of segments visualized to determine a viability index. The viability index was significantly related to 3-year survival free of cardiac event (cardiac death or heart transplant) after bypass surgery (P=.011) and was independent of age, ejection fraction, and number of diseased coronary vessels. Patients with greater viability (group 1; viability index > 0.67; n=33) were similar to patients with less viability (group 2; viability index < or = 0.67; n=37) with respect to age, comorbidities, and extent of coronary artery disease. There were 6 cardiac deaths and no heart transplants in group 1 patients and 15 cardiac deaths and two transplants in group 2 patients. Survival free of cardiac death or transplantation was significantly better in group 1 patients on Kaplan-Meier analysis (P=.018). CONCLUSIONS: We conclude that resting 201Tl scintigraphy may be useful in preoperative risk stratification for identification of patients more likely to benefit from surgical revascularization.

Coronary artery disease in women: a population-based perspective.

Coronary artery disease (CAD) remains a disease of major public health importance among women. In light of this fact, attention has focused recently on the differential expression of the disease in women as compared to men. This review will attempt to describe the characteristics of CAD among women from a population-based perspective.

Gender differences in the treatment of patients with acute myocardial infarction. A multihospital, community-based perspective.

OBJECTIVE: As part of a community-wide study examining temporal trends in the incidence and survival rates of acute myocardial infarction, we examined differences between the sexes in overall utilization rates and changes over time, therein, of various therapies used in the management of acute myocardial infarction. DESIGN: Nonconcurrent prospective study. PATIENTS: Three thousand three hundred sixty-one men and 2119 women hospitalized with validated acute myocardial infarction in 16 hospitals in the Worcester, Mass, metropolitan area during 1975, 1978, 1981, 1984, 1986, 1988, and 1990. RESULTS: After controlling, by means of a logistic regression analysis, for a variety of patient-related factors that could affect physician prescribing patterns, women were significantly more likely to receive diuretics during hospitalization for acute myocardial infarction, whereas men were significantly more likely to receive antiplatelet agents, lidocaine, and other antiarrhythmic agents. No statistically significant differences were seen between men and women with regard to the use of anticoagulants, beta-blockers, calcium channel blockers, digoxin, nitrates, and thrombolytic agents. Marked increases over time (1975 through 1990) were seen in the use of anticoagulants, antiplatelet agents, beta-blockers, lidocaine, and nitrates in each of the sexes, while declines were seen in the use of digoxin and diuretics. Use of thrombolytic therapy increased between 1986 and 1990, whereas use of calcium channel blockers decreased over this period for both men and women. CONCLUSIONS: The results of this multihospital, population-based, observational study suggest that physician practice patterns in the pharmacologic treatment of men and women hospitalized with acute myocardial infarction are very similar.