Fatal myocardial rupture after acute myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: the VALsartan In Acute myocardial iNfarcTion Trial (VALIANT).

BACKGROUND: Myocardial rupture is a relatively rare and usually fatal complication of myocardial infarction (MI). Early recognition of patients at greatest risk of myocardial rupture provides an opportunity for early intervention. METHODS: VALIANT was a double-blind, randomized, controlled trial comparing valsartan, captopril, and their combination in high-risk patients post-MI. Myocardial rupture was identified by autopsy (available in 138/589 patients dying within 30 days of index MI), echocardiography, direct surgical visualization, or presence of hemopericardium. An independent clinical end points committee reviewed medical records for all deaths or suspected nonfatal cardiovascular events. RESULTS: Rupture was identified in 45 (0.31%) patients enrolled in VALIANT, occurring 9.8 +/- 6.0 days after the qualifying MI. Rupture accounted for 7.6% (45/589) of all deaths occurring in the first 30 days of follow-up and 24% (33/138) of deaths in which autopsies were obtained. Compared with survivors, rupture was associated with increased age, hypertension, increased Killip class, lower estimated glomerular filtration rate, and Q wave MI, and inversely related to beta-blocker and diuretic use. Compared with patients who died of other causes within 30 days, patients with myocardial rupture were more likely to have had an inferior MI, Q wave MI, or hypertension; to have used oral anticoagulants; or to have received thrombolytic therapy. CONCLUSIONS: Although rare, myocardial rupture accounted for nearly one fourth of all deaths within the first 30 days after high-risk MI, suggesting an estimated incidence of approximately 1% within the first 30 days. A number of clinical characteristics may identify post-MI patients at higher risk of myocardial rupture.

Adjunct therapy in STEMI intervention.

ST-elevation myocardial infarction (STEMI) interventions have significantly reduced mortality and morbidity from acute myocardial infarction. Compulsive management of thrombus is a fundamental requirement of these interventions. A pragmatic thrombus-guided management strategy is reviewed along with additional novel therapeutic adjuncts for STEMI interventions.

Optimizing door-to-balloon times for STEMI interventions - Results from the SINCERE database.

BACKGROUND: Primary angioplasty decreases mortality and improves long-term outcomes for patients with STEMI. To be most effective, it needs to be performed expediently, with door-to-balloon times (D2B) less than 90 min. METHODS: From January 2005 to presently, 420 short D2B STEMI interventions were performed at 5 community hospitals by a single experienced operator creating the SINCERE (Single INdividual Community Experience REgistry) database. RESULTS: Median D2B time was 78 min, median procedure time (local anesthesia to recanalization) was 13 min; 85.2% of procedures had D2B time <90 min; 95% of the procedures were successful - relief of chest pain, >70% ST segment resolution, TIMI 3 flow and Myocardial Perfusion Grade 3. CONCLUSIONS: Primary PCI with high success rates and predictable short D2B times can be performed with standardized techniques in community hospitals.