Late outcomes of ST-elevation myocardial infarction treated by pharmaco-invasive or primary percutaneous coronary intervention.

AIMS: Pharmaco-invasive percutaneous coronary intervention (PI-PCI) is recommended for patients with ST-elevation myocardial infarction (STEMI)who are unable to undergo timely primary PCI (pPCI). The present study examined late outcomes after PI-PCI (successful reperfusion followed by scheduled PCI or failed reperfusion and rescue PCI)compared with timely and late pPCI (>120 min from first medical contact). METHODS AND RESULTS: All patients with STEMI presenting within 12 h of symptom onset, who underwent PCI during their initial hospitalization at Liverpool Hospital (Sydney), from October 2003 to March 2014, were included. Amongst 2091 STEMI patients (80% male), 1077 (52%)underwent pPCI (68% timely, 32% late), and 1014 (48%)received PI-PCI (33% rescue, 67% scheduled). Mortality at 3 years was 11.1% after pPCI (6.7% timely, 20.2% late) and 6.2% after PI-PCI (9.4% rescue, 4.8% scheduled); P < 0.01. After propensity matching, the adjusted mortality hazard ratio (HR) for timely pPCI compared with scheduled PCI was 0.9 (95% CIs 0.4-2.0) and compared with rescue PCI was 0.5 (95% CIs 0.2-0.9). The adjusted mortality HR for late pPCI, compared with scheduled PCI was 2.2 (95% CIs 1.2-3.1)and compared with rescue PCI, it was 1.5 (95% CIs 0.7-2.0). CONCLUSION: Patients who underwent late pPCI had higher mortality rates than those undergoing a pharmaco-invasive strategy. Despite rescue PCI being required in a third of patients, a pharmaco-invasive approach should be considered when delays to PCI are anticipated, as it achieves better outcomes than late pPCI.

Robotic Assisted Percutaneous Coronary Intervention: Initial Australian Experience.

BACKGROUND & AIM: Robotic-assisted percutaneous coronary intervention (R-PCI) has been increasingly performed overseas. Initial observations have demonstrated its clinical efficacy and safety with additional potential benefits of more accurate lesion assessment and stent deployment, with reduced radiation exposure to operators and patients. However, data from randomised controlled trials or clinical experience from Australia are lacking. METHODS: This was a single-centre experience of all patients undergoing R-PCI as part of the run-in phase for an upcoming randomised clinical trial (ACTRN12623000480684). All R-PCI procedures were performed using the CorPath GRX robot (Corindus Vascular Robotics, Waltham, Massachusetts, USA). Key inclusion criteria included patients with obstructive coronary disease requiring percutaneous coronary intervention. Major exclusion criteria included ST-elevation myocardial infarction, cardiogenic shock or lesions deemed unsuitable for R-PCI by the operator. Clinical success was defined as residual stenosis <30% without in-hospital major adverse cardiovascular events (MACE). Technical success was defined as the completion of the R-PCI procedure without unplanned manual conversion. Procedural characteristics were compared between early (cases 1-3) and later (cases 4-21) cases. RESULTS: Twenty-one (21) patients with a total of 24 lesions were analysed. The mean age of patients was 66.5 years, and 66% of cases were male. Radial access was used in 18 cases (86%). Most lesions were American Heart Association/American College of Cardiology class B2/C (66%). Clinical success was achieved in 100% with manual conversion required in four cases (19%). No procedural complications or in-hospital MACE occurred. Compared to the early cases, later cases had a statistically significantly shorter fluoroscopy time (44.0mins vs 25.2mins, p<0.007), dose area product (967.3 dGy.cm2 vs 361.0dGy.cm2, p=0.01) and air kerma (2484.3mGy vs 797.4mGy, p=0.009) with no difference in contrast usage (136.7mL vs 131.4mL, p=0.88). CONCLUSIONS: We present the first clinical experience of R-PCI in Australia using the Corindus CorPath GRX robot. We achieved clinical success in all patients and technical success in the majority of cases with no procedural complications or in-hospital MACE. With increasing operator and staff experience, cases required shorter fluoroscopy time and less radiation exposure but similar contrast usage.

Utility of prehospital electrocardiogram interpretation in ST-segment elevation myocardial infarction utilizing computer interpretation and transmission for interventional cardiologist consultation.

OBJECTIVES: We examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL-A) in ST-segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation. BACKGROUND: The incremental benefit of prehospital electrocardiogram (PH-ECG) transmission on the diagnostic accuracy and appropriateness of CCL-A has been examined in a small number of studies with conflicting results. METHODS: We identified consecutive PH-ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL-A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL-A rate. Secondary outcomes included rates of false-positive CCL-A, inappropriate CCL-A, and inappropriate CCL nonactivation. RESULTS: Among 1088 PH-ECG transmissions, there were 565 (52%) CCL-As and 523 (48%) CCL nonactivations. The appropriate CCL-A rate was 97% (550 of 565 CCL-As), of which 4.9% (n = 27) were false-positive. The inappropriate CCL-A rate was 2.7% (15 of 565 CCL-As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST-segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST-segment elevation (n = 20, 4.0%), and others. CONCLUSIONS: PH-ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false-positive CCL-As, whereas using UGA alone would have almost doubled CCL-As. The benefits of cardiologist consultation were identifying "masquerading" STEMI and avoiding unnecessary CCL-As.

Rationale for targeted self-management strategies for breathlessness in heart failure.

To provide a conceptual rationale for targeted self-management strategies for breathlessness in chronic heart failure. Breathlessness is a defining symptom of chronic heart failure and is the primary cause for hospital readmissions and emergency room visits, resulting in extensive health care utilization. Chronic breathlessness, punctuated by acute physiological decompensation, is a sentinel symptom of the heart failure syndrome and often intensifies towards the end of life. Drawing upon evidence-based guidelines, physiological mechanisms and existing conceptual models for the management of breathlessness is proposed. Key elements of this model include adherence to evidence-based approaches (pharmacological and non-pharmacological management to optimize heart failure treatment), self-monitoring of symptoms, identification of modifiable factors (such as fluid overload), and targeted strategies for breathlessness including distraction and gas flow. Self-management is an essential component in heart failure management which could positively influences health outcomes and quality of life. Refining programs to focus on breathlessness may have the potential to reduce symptom burden and improve quality of life.

Right ventricular myocardial infarction: pathophysiology, clinical implications and management.

Right ventricular myocardial infarction (RVMI) and right ventricular (RV) failure are complications from an acute occlusion of a dominant right coronary artery (RCA) or left anterior descending (LAD) artery. Although some patients have good long-term RV recovery, RVMI is associated with high rates of in-hospital morbidity and mortality driven by hemodynamic compromise, cardiogenic shock, and electrical complications. As such, it is important to identify specific clinical signs and symptoms, initiate resuscitation and commence reperfusion therapy with fibrinolytic therapy or percutaneous coronary intervention. This review will discuss RVMI pathophysiology, describe the current diagnostic measures, highlight current therapies, and explore future management options.

Comparing the clinical and prognostic impact of proximal versus nonproximal lesions in dominant right coronary artery ST-elevation myocardial infarction.

OBJECTIVE: To evaluate the prognostic significance of culprit lesion location in dominant right coronary artery (RCA) ST-elevation myocardial infarction (STEMI). BACKGROUND: In RCA STEMI, proximal culprit lesions have been shown to have higher rates of acute complications such as bradycardia and cardiogenic shock (CS) but data on mortality is limited. METHODS: We retrospectively identified and analyzed data from consecutive patients with a dominant RCA STEMI who underwent either primary or rescue percutaneous coronary intervention (PCI) between January 2003 and December 2016. We compared the rates of sustained ventricular tachycardia (VT), CS, intra-aortic balloon pump (IABP), temporary cardiac pacing (TCP) and death between culprit lesions located proximal and distal to the origin of the last right ventricular (RV) marginal artery >1 mm in diameter. RESULTS: The 939 patients were included; 599 (63.7%) had a proximal lesion and 340 (36.3%) had a nonproximal lesion. The 801 (85.3%) underwent primary PCI and 138 (14.7%) underwent rescue PCI. There was no difference in first medical contact to balloon or fibrinolysis times between the groups; p = .98 and .71. There was no significant difference in the rate of sustained VT (3.0%vs. 3.2%, p = .85) but proximal lesions were more likely to develop CS (10.9%vs. 5.8%, p = .01), require IABP (7.3%vs.2.9%, p < .01) and TCP (6.3%vs. 2.6%, p = .01). Thirty-day mortality was higher for proximal lesions (5.0%vs. 0.9%, p < .01) particularly for those with CS (35.3%vs. 10.0%, p = .05). CONCLUSION: Culprit lesions located proximal to the origin of the last RV marginal artery had a higher rate of acute complications such as CS and mortality.

Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial.

BACKGROUND: Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. METHODS: We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. RESULTS: One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86-1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). CONCLUSIONS: Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. TRIAL REGISTRATION: ANZCTRN12611000076976 Retrospectively registered.

Assessing Coronary Microvascular Dysfunction in Ischaemic Heart Disease: Little Things Can Make a Big Difference.

The role of coronary microvascular dysfunction (CMD) in the pathogenesis of ischaemic heart disease and in determining long-term prognosis is increasingly recognised. In selected patients, a comprehensive coronary assessment including an assessment of microvascular function may help refine risk stratification and improve patient outcomes. Various non-invasive and invasive techniques have been developed to assess the coronary microcirculation. Many of these tests utilise the indicator-dilution principle to determine coronary or myocardial blood flow. However, these techniques are often limited by their variability and lack of specificity for the coronary microvasculature. Consequently, there is still paucity of data on targeted therapies for CMD and their implications on long-term clinical outcomes, particularly in the setting of non-ST elevation acute coronary syndromes. Recent technical advancements, such as the index of microcirculatory resistance, have largely overcome these limitations and are able to provide novel insights into the assessment and treatment of CMD. This review summarises the currently available techniques for the assessment of CMD and provides an overview of its clinical implications.

Left atrial function to identify patients with atrial fibrillation at high risk of stroke: new insights from a large registry.

Aims: Atrial fibrillation (AF) is an independent risk factor for ischaemic stroke. The CHA2DS2-VASc is the most widely used risk stratification model; however, echocardiographic refinement may be useful, particularly in low risk AF patients. The present study examined the association between advanced echocardiographic parameters and ischaemic stroke, independent of CHA2DS2-VASc score. Methods and results: One thousand, three hundred and sixty-one patients (mean age 65±12 years, 74% males) with first diagnosis of AF and baseline transthoracic echocardiogram were followed by chart review for the occurrence of stroke over a mean of 7.9 years. Left atrial (LA) volumes, LA reservoir strain, P-wave to A' duration on tissue Doppler imaging (PA-TDI, reflecting total atrial conduction time), and left ventricular (LV) global longitudinal strain (GLS) were evaluated in patients with and without stroke. The independent association of these echocardiographic parameters with the occurrence of ischaemic stroke was evaluated with Cox proportional hazard models. One-hundred patients (7%) developed an ischaemic stroke, representing an annualized stroke rate of 0.9%. The incident stroke rate in the year following the first diagnosis of AF was 2.6% in the entire population and higher than the remainder of the follow-up period. Left atrial reservoir (14.5% vs. 18.9%, P = 0.005) and conduit strains were reduced (10.5% vs. 13.5%, P = 0.013), and PA-TDI lengthened (166 ms vs. 141 ms, P < 0.001) in the stroke compared with non-stroke group, despite similar LV dimensions, LV ejection fraction, GLS, and LA volumes. Left atrial reservoir strain and PA-TDI were independently associated with risk of stroke in a model including CHA2DS2-VASc score, age, and anticoagulant use. Conclusion: The assessment of LA reservoir strain and PA-TDI on echocardiography after initial CHA2DS2-VASc scoring provides additional risk stratification for stroke and may be useful to guide decisions regarding anticoagulation for patients upon first diagnosis of AF.

3D Echo in Routine Clinical Practice - State of the Art in 2019.

Three-dimensional (3D) echo has been around for almost five decades. Recent advances in ultrasound, electronic and computing technologies have moved 3D echo from the research environment to everyday clinical practice. Real time 3D echo and full volume acquisition are now possible with transthoracic as well as transoesophageal probes. The main advantages of 3D echo are the infinite cut planes possible, allowing direct, en face, and anatomical views of cardiac structures, avoiding foreshortening and circumventing the geometric assumptions of the cardiac chambers inherent in any 2D echo techniques. Three-dimensional echo is still dependent on image quality, subjected to ultrasound artifacts and faces the compromise between spatial and temporal resolution. In routine clinical practice in 2019, we recommend a focussed 3D examination after a full 2D echo study. The area where 3D echo has been consistently shown to have superior accuracy and reproducibility over 2D echo is in the assessment of left ventricular (LV) volumes and ejection fraction. We recommend obtaining a full volume 3D echo data set from the apical window, from which LV volumes and LV global longitudinal strain can be measured. Further 3D examination can be performed depending on the pathologies identified on 2D examination. Three-dimensional echo is superior to 2D echo in the assessment of mitral valve pathologies and atrial septal defects. Furthermore, real time 3D transoesophageal echo is a very useful technique in guiding structural cardiac intervention, both before, during and after the procedure. While 3D echo is not the holy grail of echocardiography, it does represent a useful technique in selected areas of cardiac imaging.

Effects of post-discharge management on rates of early re-admission and death after hospitalisation for heart failure.

OBJECTIVES: To investigate whether enrolment of patients in management programs after hospitalisation for heart failure (HF) reduces the likelihood of post-hospital adverse outcomes. DESIGN: Cohort study in which associations between adverse outcomes at 30 and 90 days for people hospitalised for HF and baseline clinical, socio-demographic and blood pathology factors, and with post-discharge management strategies, were assessed. Setting, participants: 906 patients with HF were prospectively enrolled in five Australian states at cardiology departments with expertise in treating people with HF. MAIN OUTCOME MEASURES: All-cause re-admissions and deaths at 30 and 90 days after discharge from the index admission. RESULTS: 58% of patients were men; the mean age was 72.5 years (SD, 13.9 years). By hospital, 30-day re-admission rates ranged from 17% to 33%, and 90-day rates from 40% to 55%; 30-day mortality rates were 0-13%, 90-day rates 4-24%. Factors associated with increased odds of re-admission or death at 30 or 90 days included living alone, cognitive impairment, depression, NYHA classification, left atrial volume index, and Charlson index score. Nurse-led disease management programs and reviews within 7 days were associated with reduced odds of re-admission (but not of death) at 30 and 90 days; exercise programs were associated with reduced odds at 90 days. Significant between-hospital differences in re-admission rates were reduced after adjustment for post-discharge management programs, and abolished by further adjustment for echocardiography findings. Between-hospital differences in mortality were largely explained by differences in echocardiographic findings. CONCLUSIONS: Differences in early re-admission rates after hospitalisation for HF are primarily explained by differences in post-discharge management.

Left atrial function: Correlation with left ventricular function and contractile reserve in patients with hypertension.

AIMS: Alterations in left atrial (LA) and left ventricular (LV) function have been documented in hypertensive patients. However, the correlation of LA with LV functional changes has not been established. Using normotensive controls, we examined LA functional changes in hypertensive patients by strain deformation analysis, and their relationship to LV functional changes including contractile reserve (CR). METHODS: One hundred and sixteen patients (61 men, aged 57.6 ± 9.1 years, 67 with hypertension) underwent dobutamine echocardiography. Patients with significant coronary or valvular disease, previous myocardial infarction or coronary revascularization, and diabetes were excluded. LA reservoir (Ɛs), conduit (Ɛe), and atrial contractile (Ɛa) strain were measured at rest. LV global longitudinal strain (GLS) and ejection fraction (LVEF) were measured at rest and at low-dose dobutamine. LV CR was calculated as the difference in GLS and LVEF between the low dose and their corresponding resting values. RESULTS: Hypertensive patients, compared with controls, had significantly impaired LA Ɛs (30.7 ± 3.9% vs 42.4 ± 4.9%), Ɛe (16.2 ± 4.1% vs 22.5 ± 5.5%), and Ɛa (14.5 ± 4.1% vs 19.9 ± 5.0%, all P < .001) strain. All LA phasic strain correlated with LV GLS at rest, at low-dose dobutamine, and LV CR. There was no correlation between LA strain and LVEF or LV CR assessed by LVEF. LV GLS and LAVImax were the strongest independent determinants for LA Ɛs/Ɛe and LA Ɛa, respectively. CONCLUSION: Compared to controls, hypertensive patients had impaired LA strain, which correlated with LV GLS and CR. LV GLS and LAVImax were the strongest independent determinants for LA Ɛs/Ɛe and LA Ɛa, respectively, independent of BP and LVMi.

Differential Myocardial Fibre Involvement by Strain Analysis in Patients With Aortic Stenosis.

BACKGROUND: Aortic stenosis (AS) is the most common valvular heart disease and can result in left ventricular (LV) systolic impairment. LV myocardial fibres are organised in layers: the subendocardial layer is orientated longitudinally and the subepicardial layer circumferentially. We hypothesised that there is differential involvement of myocardial fibres in patients with aortic stenosis. METHODS: We performed multi-directional, multi-layered systolic strain analysis in 70 patients (aged 72±10.7years) with varying grades of AS severity (mean gradient 32.3±20mmHg, aortic valve area 1.1±0.6cm2) and in 30 controls. Clinical, demographic and resting echocardiographic data were recorded. Left ventricular subendocardial and subepicardial systolic strains were measured in the longitudinal, radial and circumferential axes. RESULTS: Systolic subendocardial strain was significantly higher than subepicardial strain in all three axes in patients and in controls. There were significant differences in longitudinal, but not in circumferential and radial strain, or left ventricular ejection fraction (LVEF), between patient groups. Aortic valve mean gradient (MG) and valve area (AVA) correlated better with subendocardial longitudinal strain (r=0.548, p<0.001; r=-0.54, p<0.001 respectively) than with subepicardial longitudinal strain (r=0.496, p<0.001, r=-0.544, p<0.001 respectively). Correlations between circumferential and radial strain and MG or AVA were poor. CONCLUSIONS: There was differential impairment in LV systolic strain in all three cardiac axes in patients with AS. Left ventricular longitudinal strain impairment was proportional to AS severity. Subendocardial longitudinal strain correlated better with AS severity than subepicardial longitudinal strain while correlations between circumferential and radial strain and AS severity were weak.

Evaluation of Serial High Sensitivity Troponin T Levels in Individuals Without Overt Coronary Heart Disease Following Exercise Stress Testing.

BACKGROUND: Detectable levels of high sensitivity (cardiac) troponin T (HsTnT), occur in the majority of patients with stable coronary heart disease (CHD), and often in 'healthy' individuals. Extreme physical activity may lead to marked elevations in creatine kinase MB and TnT levels. However, whether HsTnT elevations occur commonly after exercise stress testing (EST), and if so, whether this has clinical significance, needs clarification. METHODS: To determine whether HsTnT levels become elevated after EST (Bruce protocol) to ≥95% of predicted maximum heart rate in presumed healthy subjects without overt CHD, we assayed HsTnT levels for ∼5h post-EST in 105 subjects (median age 37 years). RESULTS: Pre-EST HsTnT levels <5 ng/L were present in 31/32 (97%) of females and 52/74 (70%) of males. Post-EST, 13 (12%) subjects developed HsTnT levels >14 ng/L, with troponin elevation occurring at least three hours post-EST. Additionally, a detectable ≥ 50% increase in HsTnT levels (4.9→9ng/L) occurred in 28 (27%) of subjects who during EST achieved ≥ 95% of their predicted target heart rate. The median age of the subjects with HsTnT elevations to > 14ng/L post-EST was higher than those without such elevation (42 and 36 years respectively; p=0.038). At a median follow-up of 13 months no adverse events were recorded. CONCLUSION: The current study demonstrates that detectable elevations occur in HsTnT post-EST in 'healthy' subjects without overt CHD. Future studies should evaluate the clinical significance of detectable elevations in post-EST HsTnT with long-term follow-up for adverse cardiac events.

The value of serial echocardiography in risk assessment of patients with paroxysmal atrial fibrillation.

Progression from paroxysmal to persistent atrial fibrillation (AF) is associated with increased morbidity and mortality. We examined the association of left atrial (LA) remodeling by serial echocardiography, and AF progression over an extended follow-up period. Two-hundred ninety patients (mean age 61  ±  11 years, 73% male) who underwent transthoracic echocardiography performed at first presentation for non-valvular paroxysmal AF (PAF) and repeat echocardiogram 1-year later, were followed for progression to persistent AF. LA and left ventricular (LV) dimensions, volumes, LA reservoir, conduit and booster pump strains, LV global longitudinal systolic strain (GLS) assessed by 2D speckle tracking, and PA-TDI (time delay between electrical and mechanical LA activation- reflecting the extent of LA fibrosis) were compared on serial echocardiography. Sixty-nine (24%) patients developed persistent AF over a mean follow-up period of 6.3 years. At baseline, patients with subsequent persistent AF had larger LA dimensions (46 mm vs. 42 mm, p < 0.001), indexed LA volumes (41 ml/m2 vs. 34 ml/m2, p < 0.001), lower LA reservoir and conduit strain (17.6% vs. 27.6%, p < 0.001; 10.5% vs. 16.3%, p < 0.001; respectively) and longer PA-TDI (155 ms vs. 132 ms, p < 0.001) compared to the PAF group. Patients with subsequent persistent AF showed over time significant enlargement in LA volumes (from 37.7 ml/m2 to 42.4 ml/m2, p < 0.001), lengthening of PA-TDI (from 142.2 ms to 162.2 ms, p = 0.002), and decline in LA reservoir function (from 21.9% to 18.1%, p = 0.024) after adjusting for age, gender, diabetes and LV GLS. There were no changes in LA diameter, LA conduit or booster pump function. Conversely, the PAF group showed no decline in LA function. Patients who developed persistent AF had larger LA size and impaired LA function and atrial conduction times at baseline, compared to patients who remained PAF. Over the 1-year time course of serial echocardiographic evaluation, there was progression of LA remodeling in patients who subsequently developed persistent AF, but not in patients who remained in PAF.

Bare-metal stenting of large coronary arteries in ST-elevation myocardial infarction is associated with low rates of target vessel revascularization.

BACKGROUND: During percutaneous coronary intervention (PCI) performed in the emergent setting of ST-segment elevation myocardial infarction (STEMI), uncertainty about patients' ability to comply with 12 months dual antiplatelet therapy after drug-eluting stenting is common, and thus, selective bare-metal stent (BMS) deployment could be an attractive strategy if this achieved low target vessel revascularization (TVR) rates in large infarct-related arteries (IRAs) (≥3.5 mm). METHODS AND RESULTS: To evaluate this hypothesis, among 1,282 patients with STEMI who underwent PCI during their initial hospitalization, we studied 1,059 patients (83%) who received BMS, of whom 512 (48%) had large IRAs ≥3.5 mm in diameter, 333 (31%) had IRAs 3 to 3.49 mm, and 214 (20%) had IRAs <3 mm. At 1 year, TVR rate in patients with BMS was 5.8% (2.2% with large BMS [≥3.5 mm], 9.2% with BMS 3-3.49 mm [intermediate], and 9.0% with BMS <3.0 mm [small], P < .001). The rates of death/reinfarction among patients with large BMS compared with intermediate BMS or small BMS were lower (6.6% vs 11.7% vs 9.0%, P = .042). Among patients who received BMS, the independent predictors of TVR at 1 year were the following: vessel diameter <3.5 mm (odds ratio [OR] 4.39 [95% CI 2.24-8.60], P < .001), proximal left anterior descending coronary artery lesions (OR 1.89 [95% CI 1.08-3.31], P = .027), hypertension (OR 2.01 [95% CI 1.17-3.438], P = .011), and prior PCI (OR 3.46 [95% CI 1.21-9.85], P = .02). The predictors of death/myocardial infarction at 1 year were pre-PCI cardiogenic shock (OR 8.16 [95% CI 4.16-16.01], P < .001), age ≥65 years (OR 2.63 [95% CI 1.58-4.39], P < .001), left anterior descending coronary artery culprit lesions (OR 1.95 [95% CI 1.19-3.21], P = .008), female gender (OR 1.93 [95% CI 1.12-3.32], P = .019), and American College of Cardiology/American Heart Association lesion classes B2 and C (OR 2.17 [95% CI 1.10-4.27], P = .026). CONCLUSION: Bare-metal stent deployment in STEMI patients with IRAs ≥3.5 mm was associated with low rates of TVR. Their use in this setting warrants comparison with second-generation drug-eluting stenting deployment in future randomized clinical trials.

Rationale and design of a randomized trial on the impact of aldosterone antagonism on cardiac structure and function in diabetic cardiomyopathy.

UNLABELLED: Development of a cardiomyopathy in diabetes mellitus is independent of traditional risk factors, with no clinical trials targeting specific therapeutic interventions. Myocardial fibrosis is one of the key mechanisms and aldosterone is a key mediator of myocardial fibrosis. We propose that aldosterone antagonism will improve cardiac function. We aim to evaluate the efficacy of selective aldosterone receptor antagonism with eplerenone added to optimal medical treatment in improving cardiac structure and function in diabetic cardiomyopathy. We will randomize 130 patients with type 2 diabetes mellitus, stable metabolic control and impaired left ventricular (LV) systolic or diastolic function, to either eplerenone (target dose 50mg) or matching placebo, in addition to optimal medical therapy for 12 months. The primary endpoints are changes in LV systolic and diastolic function, measured by echocardiographic 2-dimensional speckle tracking strain and strain rate and tissue Doppler imaging. The secondary endpoints include changes in echocardiographic markers and plasma biomarkers of collagen turnover; left atrial dimensions and function, incidence of atrial fibrillation and changes in exercise capacity and dyspnea score. The present study will assess whether specific aldosterone antagonism with eplerenone in addition to standard therapy will prevent progression or reverse cardiac dysfunction in diabetic cardiomyopathy using sensitive, robust and quantifiable echocardiographic measures that allow early detection of change. The study may offer a new direction in the management of this condition. TRIAL REGISTRATION: ACTRN12610001063000.

Evaluation of a policy of selective drug-eluting stent implantation for patients at high risk of restenosis.

Drug-eluting stent (DES) deployment during percutaneous coronary intervention (PCI) has reduced target-vessel revascularisation rates (TVR). The selective use of DES in patients at highest risk of restenosis may allay concerns about universal compliance of dual antiplatelet therapy for one year, and potentially reduce costs. If this strategy achieved acceptably low TVR rates, such an approach could be attractive. Late clinical outcomes were examined in 2115 consecutive patients (mean age 63±12 years, 75% male, 22% diabetics) who underwent PCI in the first three years from October 2003, after commencing the following selective criteria for DES use: left main stenosis; ostial lesions of major epicardial arteries; proximal LAD lesions; lesions≥20mm in length with vessel diameter≤3.0mm; lesions in vessels≤2.5mm; diabetics with vessel(s)≤3.0mm; and in-stent restenosis. Among patients undergoing PCI, 2075 (98%) patients received stents (29%≥1 DES and 71% bare metal stent [BMS]), and among those who received DES, there was a 92% compliance with these criteria. There were no differences in clinical outcomes between the two stent groups except for definite stent thrombosis, which occurred in 2% after DES, and 0.6% after BMS at one year (p=0.002). With BMS, large coronary arteries (≥3.5mm), intermediate (3-3.49mm) and small arteries (<3mm) in diameter had a TVR rate at one year of 3.6%, 7.2% and 8.2% respectively (p=0.005). It is possible to use selective criteria for DES while maintaining low TVR rates. The TVR rate with BMS was low in those with stent diameters≥3.5mm. The higher DES stent thrombosis rate reflects first generation DES use, though whether routine second generation DES use reduces these rates needs confirmation.