A comparison of gamma-glutamyl transferase and alkaline phosphatase as prognostic markers in patients with coronary heart disease.

BACKGROUND AND AIMS: Whether gamma-glutamyl transferase (GGT) or alkaline phosphatase (ALP) is a better prognostic marker in patients with coronary heart disease (CHD) remains unknown. The aim of this study was to compare the prognostic value of GGT and ALP in patients with CHD. METHODS AND RESULTS: This study included 3768 patients with CHD. The main study outcome was 3-year all-cause mortality. The median values of GGT and ALP were 36.2 U/L and 69.3 U/L. Patients were divided into subgroups according to GGT or ALP activity > or ≤median. Overall, there were 304 deaths: 195 deaths occurred in patients with GGT >median (n = 1882) and 109 deaths occurred in patients with GGT ≤median (n = 1886); Kaplan-Meier [KM] estimates of all-cause mortality were 11.9% and 6.4% (unadjusted hazard ratio [HR] = 1.85, 95% confidence interval [CI], 1.46 to 2.34]; P < 0.001). According to ALP activity, 186 deaths occurred in patients with ALP >median (n = 1883) and 118 deaths occurred in patients with ALP ≤median (n = 1885); KM estimates of all-cause mortality were 11.4% and 7.1% (unadjusted HR = 1.64 [1.30-2.06]; P < 0.001). After adjustment, GGT (adjusted HR = 1.32 [1.11-1.58]; P = 0.002) but not ALP (adjusted HR = 1.20 [1.00-1.43]; P = 0.051, with both HR calculated per 1 unit increment in logarithmic GGT or ALP scale) remained significantly associated with the risk for mortality. The C statistic of the mortality model with GGT was greater than the C statistic of the model with ALP (0.831 [0.802-0.859] vs. 0.826 [0.793-0.855]; P < 0.001). CONCLUSIONS: In patients with CHD, GGT was a stronger correlate of all-cause mortality than ALP.

A gender-specific analysis of association between hyperuricaemia and cardiovascular events in patients with coronary artery disease.

BACKGROUND AND AIMS: Gender-related differences in the association between hyperuricaemia and cardiovascular events remain poorly understood. The objective of this study was to assess gender-related differences in the association between hyperuricaemia and cardiovascular events in patients with coronary artery disease (CAD). METHODS AND RESULTS: This study included 13,273 patients with CAD. Hyperuricaemia was defined as a plasma uric acid >7.0mgdl(-1) in men and >5.7mgdl(-1) in women. The primary outcome was 1-year all-cause mortality. Hyperuricaemia was found in 3745 men (36.5%) and 1562 women (50.3%); odds ratio (OR)=1.76, 95% confidence interval (CI) 1.62-1.91; P<0.001. Women with hyperuricaemia were older, had higher proportions of patients with diabetes and arterial hypertension and had reduced renal function and higher C-reactive protein levels compared with men with hyperuricaemia. One-year all-cause mortality was 9.3% (n=143) in women with hyperuricaemia versus 6.9% (n = 252) in men with hyperuricaemia (P=0.002). After adjustment in multivariable Cox proportional hazards model, uric acid predicted 1-year mortality with an adjusted hazard ratio (HR)=1.17, 95% CI (1.03-1.31), P=0.012 in men and HR=1.25, 95% CI (1.06-1.48), P=0.007 in women, for each standard deviation increase in the natural logarithm. Uric acid predicted 1-year mortality with an area under the receiver-operating characteristic curve=0.625, 95% CI (0.594-0.656) in men and 0.676, 95% CI (0.635-0.717) in women (P=0.044, for women versus men). CONCLUSION: Hyperuricaemia predicts an increased risk of 1-year mortality in both genders with a stronger association in women. Differences in cardiovascular risk profile may explain the stronger association between hyperuricaemia and cardiovascular events in women.

Aspirin and clopidogrel with or without phenprocoumon after drug eluting coronary stent placement in patients on chronic oral anticoagulation.

OBJECTIVES: Optimal antithrombotic/anticoagulation therapy in patients on chronic oral anticoagulation (OAC) undergoing drug-eluting stent (DES) implantation is unknown. We investigated the efficacy and safety of two regimens of antithrombotic/anticoagulation therapy in patients who present for DES implantation whilst on OAC. METHODS: We included a series of 515 patients on OAC who underwent DES implantation between 2002 and 2007. Based on predefined clinical and echocardiographic criteria, 306 patients continued OAC (triple therapy) and 209 patients discontinued OAC (dual therapy) for the time they received antiplatelet therapy with clopidogrel and aspirin [stent-related antithrombotic treatment (SRAT)]. The primary end point was a composite of death, myocardial infarction, stent thrombosis or stroke. RESULTS: During SRAT the primary endpoint was observed in 13 patients in the group with triple therapy versus 15 patients in the group with dual therapy [Kaplan-Meier estimates 4.2% and 7.2%, odds ratio (OR) = 0.61, 95% confidence interval (CI) 0.29-1.28; P = 0.19]. At 2 years of follow-up, the primary endpoint was observed in 35 patients in the group with triple therapy versus 36 patients in the group with dual therapy (Kaplan-Meier estimates 14.1% and 18.0%, OR = 0.76, 95% CI: 0.48-1.21; P = 0.25). Two-year incidence of major bleeding was 1.4% (n = 4, triple therapy) versus 3.1% (n = 6, dual therapy) (P = 0.34). CONCLUSIONS: In patients on chronic OAC undergoing DES implantation, clinical and echocardiographic criteria help to define postprocedural antithrombotic/anticoagulation therapy. Based on these criteria, both a double antiplatelet therapy (clopidogrel plus aspirin) and a triple therapy (OAC plus clopidogrel plus aspirin) are associated with favourable safety and efficacy.

Myeloperoxidase level in patients with stable coronary artery disease and acute coronary syndromes.

BACKGROUND: No studies have measured plasma myeloperoxidase (MPO) across the entire spectrum of patients with coronary artery disease (CAD). The aim of the study was to compare MPO level across the entire spectrum of CAD, to assess the accuracy of MPO in predicting acute coronary syndromes and to define independent correlates of MPO level. DESIGN: This case-control study included 874 patients with angiographically proven CAD. Cases included 680 patients with CAD (382 patients with stable CAD, 107 patients with non-ST-segment elevation acute coronary syndromes and 191 patients with ST-segment elevation acute myocardial infarction). Controls included 194 subjects with normal coronary angiograms. MPO was measured using an enzyme immunoassay before angiography and heparin administration. RESULTS: MPO level [median (25th-75th percentiles)] was 74.5 (52.5-135.3) microg L(-1) in cases vs. 61.2 (44.6-80.9), microg L(-1) in controls (P < 0.001). MPO level was 61.2 (47.5-85.8), microg L(-1) in patients with stable CAD, 99.2 (62.2-154.9), microg L(-1) in patients with non-ST-segment elevation acute coronary syndromes and 129.5 (72.2-216.0) microg L(-1) in patients with acute myocardial infarction (P < 0.001). Elevated MPO level was associated with acute coronary syndromes with an area under receiver operating characteristic (ROC) curve of 0.731 (95% confidence interval 0.692-0.770; P < 0.001). Independent correlates of MPO level were acute coronary syndrome (P < 0.001), high-sensitivity C-reactive protein (P = 0.007), creatinine (P = 0.026), left ventricular ejection fraction (P = 0.027, negative association) and smoking (P = 0.028). CONCLUSIONS: MPO level is elevated in patients with CAD and higher levels of MPO were found with progression of CAD from stable CAD to non-ST-segment elevation acute coronary syndromes and to acute myocardial infarction.

Clinical experience with a novel multielectrode basket catheter in right atrial tachycardias.

BACKGROUND: The complexity of atrial tachycardias (ATs) makes the electroanatomic characterization of the arrhythmogenic substrate difficult with conventional mapping techniques. The aim of our study was to evaluate possible advantages of a novel multielectrode basket catheter (MBC) in patients with AT. METHODS AND RESULTS: In 31 patients with AT, an MBC composed of 64 electrodes was deployed in the right atrium (RA). The possibility of deployment, spatial relations between MBC and RA, MBC recording and pacing capabilities, mapping performance, and MBC-guided ablation were assessed. MBC deployment was possible in all 31 patients. The MBC was left in the RA for 175+/-44 minutes. Stable bipolar electrograms were recorded in 88+/-4% of electrodes. Pacing from bipoles was possible in 64+/-5% of electrode pairs. The earliest activity intervals, in relation to P-wave onset, measured from the MBC and standard roving catheters were 41+/-9 and 46+/-6 ms, respectively (P=0.21). Radiofrequency ablation was successful in 15 (94%) of 16 patients in whom it was attempted, including 2 patients with polymorphic right atrial tachycardia (RAT), 2 with RAT-atrial flutter combination, 1 with macroreentrant AT, and 1 with focal origin of atrial fibrillation. CONCLUSIONS: These data demonstrate that MBC can be used safely in patients with right atrial arrhythmias. The simultaneous multielectrode mapping aids in the rapid identification of sites of origin of the AT and facilitates radiofrequency ablation procedures. The technique is especially effective for complex atrial arrhythmias.

Value of programmed ventricular stimulation for prophylactic internal cardioverter-defibrillator implantation in postinfarction patients preselected by noninvasive risk stratifiers.

OBJECTIVES: The aim of this prospective study was to evaluate the role of programmed ventricular stimulation (PVS) after noninvasive risk stratification to identify a subgroup of acute myocardial infarction (AMI) survivors considered at risk for ventricular arrhythmias and whether these patients could benefit from internal cardioverter-defibrillators (ICDs). BACKGROUND: The predictive value of noninvasive and invasive risk stratifiers after AMI has been questioned. The question of whether the group of patients with inducible monomorphic ventricular tachycardia (VT) after AMI could profit from ICD implantation is unanswered. METHODS: A consecutive series of 1,436 AMI survivors was screened noninvasively by Holter monitoring, heart rate variability, ventricular late potentials, and ejection fraction. A subgroup of 248 patients (17.3%) were identified as high-risk patients and scheduled for PVS. Due to the study design, 54 patients >75 years were excluded; thus, 194 patients were eligible for PVS. Triple extrastimuli at two paced cycle lengths (600 ms and 400 ms) were applied. RESULTS: In a subgroup of 98 (51%) high-risk patients, PVS was performed; 21 patients had an abnormal response, and in 20 patients an ICD was implanted. During a mean follow-up of 607 days the arrhythmic event rate (sudden cardiac death, symptomatic VT, cardiac arrest) was 33% with a positive electrophysiological test versus 2.6% (p < 0.0001) with a negative electrophysiological test. A subgroup of 96 high-risk patients declined electrophysiological study. In this nonconsent group, cardiac mortality (combined sudden and nonsudden) was significantly higher (log-rank chi-square 9.38, p = 0.0022, relative risk 4.7, 1.6 to 13.9) compared to the group guided by electrophysiological testing and consecutive ICD implantation. CONCLUSIONS: After a two-step risk stratification, PVS is helpful in selecting a subgroup of AMI survivors without spontaneous ventricular arrhythmias who benefit from prophylactic ICD implantation.

Electrophysiologic characteristics of paroxysmal and chronic atrial fibrillation in human right atrium.

OBJECTIVES: The aim of the study was to analyze the electrophysiologic characteristics of paroxysmal (PAF) and chronic (CAF) atrial fibrillation (AF) in the human right atrium (RA). BACKGROUND: Differences that exist between PAF and CAF and the mechanisms of self-sustenance of these arrhythmias are incompletely understood. METHODS: A total of 53 patients with PAF (25 patients, mean age 59 +/- 6.1 years, 3 women) and CAF (28 patients, mean age 59 +/- 13 years, 7 women) underwent multisite mapping of the RA during ongoing AF using a 64-electrode basket catheter. Quantitative evaluation and three-dimensional activation patterns were performed using a computerized system. RESULTS: Patients with PAF, as compared with patients with CAF, had significantly longer AF cycle length, shorter time intervals with type III AF throughout the RA and a smaller number of endocardial breakthroughs (mean 51 +/- 19 vs. 104 +/- 40, p < 0.001). The majority of endocardial breakthrough points (88% in PAF patients and 98% in CAF patients) were located in the septal region and coincided anatomically with major interatrial connection routes. Coexistence of re-entrant and apparently focal activation determined maintenance of AF in the RA in PAF, whereas random re-entry was documented more frequently in patients with CAF. In patients with CAF, the duration of arrhythmia (in years) correlated strongly with the percentage of time during which type III AF was observed in the lateral wall of the RA (r = 0.71). CONCLUSIONS: Clinical PAF and CAF, as recorded in the RA, have, at least quantitatively, distinct electrophysiologic features and different mechanisms of maintenance.

Computer-assisted animation of atrial tachyarrhythmias recorded with a 64-electrode basket catheter.

OBJECTIVES: The aim of this study was to assess the value of a new mapping technique based on computer-assisted animation of multielectrode basket catheter (BC) recordings in patients with atrial arrhythmias. BACKGROUND: The three-dimensional activation patterns of cardiac arrhythmias are not completely understood owing to limitations of conventional mapping techniques. METHODS: The study included 32 patients with atrial tachycardia (AT) and 38 patients with atrial flutter (AFL). A software program was developed to analyze the activation patterns based on 56 bipolar electrograms recorded with a 64-electrode BC deployed in the right atrium (RA). RESULTS: The total time needed for the animation of activation patterns of atrial arrhythmias was 5 +/- 0.8 min. In 22 patients with right AT, the animated maps revealed that arrhythmia was unifocal in 15 patients, multifocal in 2 patients, polymorphic in 4 patients and reentrant in 1 patient. In 10 patients with left AT, breakthroughs on the right side of the septum (2 in 8 patients and 1 in 2 patients) and a left-to-right activation of the RA were demonstrated. In patients with typical AF, the reentrant excitation was a broad activation front with preferential propagation around the tricuspid annulus. In patients with atypical AFL, the reentry circuit involved one of the venae cavae and a line of block located in the posterior wall. CONCLUSIONS: The computer-assisted animation of multiple electrograms recorded with a BC is a valuable mapping tool that delineates the three-dimensional activation patterns of various atrial arrhythmias. The technique is appropriate for complex, short-lived or unstable arrhythmias.

Modes of initiation of paroxysmal atrial fibrillation from analysis of spontaneously occurring episodes using a 12-lead Holter monitoring system.

Although new, possibly curative radiofrequency ablation techniques for atrial fibrillation (AF) have been developed in recent years, little is known about the mechanisms of spontaneous onset of AF episodes. Using a 12-lead 24-hour Holter monitoring system, we aimed to characterize such episodes. A total of 297 spontaneous episodes of AF in 33 patients with intermittent AF (mean age of 59 +/- 11 years) were analyzed. Two hundred seventy-six episodes (93%) were initiated by atrial premature complexes (APCs), whereas 19 episodes (6.4%) were preceded by typical atrial flutter and 2 (0.7%) by atrial tachycardia. Based on 12-lead electrocardiographic criteria, the origin of ectopic beats initiating AF was classified in 230 episodes (77.5%) as being of left atrial origin, in 6 episodes (2.0%) as being of right atrial origin and in 40 episodes (13.5%) the exact location could not be determined. In 16 of 23 patients (70%) with multiple episodes of AF, ectopic beats that initiated AF were consistently monomorphic. In the 120 seconds (6.2 APCs/min for a 30-second period) before onset of AF, frequency of ectopic beats increased from 0.8 APCs/min in AF-free intervals to 4.1/min (6.2 APCs/min for a 30-second period), (p = 0.003 and p = 0.016, respectively). In 209 of 254 episodes (82%), AF onset occurred during normal sinus rate (60 to 100 beats/min). Thus, paroxysmal AF is triggered most frequently by monomorphic left APCs. In most AF episodes, the increase in the number of ectopic beats that initiated episodes of AF occurred at a normal sinus rate.

ECG changes in a 25-year-old woman with hypocalcemia due to hypoparathyroidism. Hypocalcemia mimicking acute myocardial infarction.

The case of a 25-year-old woman presenting with chest pain, ECG changes, and laboratory findings suggestive of myocardial infarction is reported. Cardiac catheterization showed impaired left ventricular performance but otherwise normal coronary arteries. Laboratory analyses revealed primary hypoparathyroidism, and supplementation with calcium and vitamin D(3) was initiated. There was subsequent improvement in laboratory findings as well as echocardiographically determined left ventricular performance. Thereafter, the patient remained asymptomatic. Apart from some persisting ECG repolarization disturbances, there was complete normalization of the initial changes. This case demonstrates a combination of clinical, blood biochemical, and ECG findings mimicking acute myocardial infarction.

Acute electrophysiologic effects and antifibrillatory actions of the long linear lesions in the right atrium in a sheep model.

UNLABELLED: Linear lesions (LL) represent an option for curing of atrial fibrillation (AF) with ablation techniques. METHODS AND RESULTS: In 11 sheep (w. 72+/-16 kg), LL were created with radiofrequency ablation in the lateral, posterior and septal walls of the right atrium (RA). AF was induced before and after LL with burst pacing. Mapping of the AF was performed with a 64-electrode basket catheter deployed in the RA. Quantitative analysis was performed with a custom-made software program. LL were confirmed histologically 7 to 10 days after the procedure. LL were transmural in 78% of their length. Stimulation thresholds and right atrial activation times were increased after LL compared to preablation values. Effective refractory periods of the RA were prolonged significantly in 7 out of 12 regions after generation of LL. Conduction velocities in the RA segments between LL were reduced in lateral, posterior and septal walls. During paced rhythms double potentials were recorded in all animals. AF could be induced in all animals of this model despite the presence of LL in the RA. AF episodes were significantly more regular after LL throughout the RA due to a significant reduction of the number of the wave fronts in the RA. During AF episodes, in the presence of LL, the RA was driven by wave fronts of left atrial origin entering the right side of the septum through interatrial connections. CONCLUSIONS: 1) LL profoundly affect electrophysiologic parameters of RA. 2) In the presence of LL, AF manifest a higher degree of regularity as compared to preablation episodes. 3) Dissociation between wave fronts of left atrial origin entering the RA through the interatrial connections is an important mechanism of the antifibrillatory action of the septal LL.

[Complete vagal block in the clinical evaluation of sinus bradycardia]. / Le blocage vagal complet dans l'évaluation clinique de la bradycardie sinusale.

The authors determined the discriminant threshold of sinus rate (SR) and the degree of its increase after complete vagal block (0.04 mg/kg of atropine sulfate IV) in 34 patients with symptomatic sinus bradycardia, the day after electrophysiological evaluation (performed before and after autonomic block with propranolol 0.2 mg/kg and atropine sulfate 0.04 mg/kg IV). Patients were divided into two groups. Group I included 19 patients (age 43.3 +/- 8) with normal intrinsic sinus automatism with normal intrinsic heart rate (IHRo) and normal intrinsic corrected sinus recovery time (intrinsic CSRT) (< 425 ms). Group II consisted of 15 patients (age 51.8 +/- 12) with abnormal intrinsic sinus automatism with abnormal IHRo and/or intrinsic CSRT (> 425 ms). Following the atropine test, SR in the individuals of Group I increased from 58.1 +/- 11.7 bpm to 103 +/- 16 bpm (delta% = 80 +/- 37), while in Group II it increased from 52.8 +/- 12 bpm to 82.15 bpm (delta% = 55.4 +/- 21). The discriminant threshold of SR and of its percentage increase (delta%) were 91 bpm and 68% respectively, with a sensitivity of 71 and 81% and a specificity of 73 and 63%. The predictive value of a positive test of SR (< 91 bpm) and of its delta% (< 68%) were 71 and 64% respectively. That of a negative test of SR (> 91 bpm) and of its delta% (< 68%) were 73 and 80% respectively. The total predictive accuracy of SR and of its percentage increase was the same: 72%.(ABSTRACT TRUNCATED AT 250 WORDS)

Índice de masa corporal y eficacia y seguridad del ticagrelor frente al prasugrel en pacientes con síndrome coronario agudo / Body mass index and efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndromes

Introducción y objetivos Siguen sin estudio la eficacia y la seguridad del ticagrelor frente al prasugrel en pacientes con síndrome coronario agudo (SCA) según el índice de masa corporal (IMC). Se evaluaron la eficacia y la seguridad del ticagrelor frente a prasugrel en pacientes con SCA según el IMC. Métodos Se agrupó a los pacientes (n=3.987) en 3 categorías: con peso normal (IMC <25; n=1.084), sobrepeso (IMC ≥ 25 <30; n=1.890) y obesidad (IMC ≥ 30; n=1.013). El objetivo primario de eficacia fue la incidencia de muerte por cualquier causa, infarto de miocardio o accidente cerebrovascular a 1 año. El objetivo secundario de seguridad fue la incidencia de hemorragias de tipo 3-5 de la Bleeding Academic Research Consortium a 1 año. Resultados El objetivo primario se produjo en 63 pacientes asignados a ticagrelor y 39 asignados a prasugrel en el grupo de peso normal (el 11,7 frente al 7,5%; HR=1,62; IC95%, 1,09-2,42; p=0,018), 78 pacientes asignados a ticagrelor y 58 asignados a prasugrel en el grupo de sobrepeso (el 8,3 frente al 6,2%; HR=1,36; IC95%, 0,97-1,91; p=0,076) y 43 pacientes asignados a ticagrelor y 37 asignados a prasugrel en el grupo de obesidad (el 8,6 frente al 7,3%; HR=1,18; IC95%, 0,76-1,84; p=0,451). La incidencia de eventos hemorrágicos a 1 año en los pacientes con peso normal (el 6,5 frente al 6,6%; p=0,990), sobrepeso (el 5,6 frente al 5,0%; p=0,566) u obesidad (el 4,4 frente al 2,8%; p=0,219) no difirió entre el ticagrelor y el prasugrel. No hubo una interacción significativa entre el brazo de tratamiento y el IMC en relación con el objetivo primario (pinteracción=0,578) o el secundario (pinteracción=0,596). Conclusiones En pacientes con SCA, el IMC no influyó significativamente en el efecto del tratamiento con ticagrelor en términos de eficacia o seguridad frente al prasugrel (AU)

Introduction and objectives The efficacy and safety of ticagrelor vs prasugrel in patients with acute coronary syndromes (ACS) according to body mass index (BMI) remain unstudied. We assessed the efficacy and safety of ticagrelor vs prasugrel in patients with ACS according to BMI. Methods Patients (n=3987) were grouped into 3 categories: normal weight (BMI <25kg/m2; n=1084), overweight (BMI ≥ 25 to <30kg/m2; n=1890), and obesity (BMI ≥ 30kg/m2; n=1013). The primary efficacy endpoint was the 1 year incidence of all-cause death, myocardial infarction, or stroke. The secondary safety endpoint was the 1 year incidence of Bleeding Academic Research Consortium type 3 to 5 bleeding. Results The primary endpoint occurred in 63 patients assigned to ticagrelor and 39 patients assigned to prasugrel in the normal weight group (11.7% vs 7.5%; HR, 1.62; 95%CI, 1.09-2.42; P=.018), 78 patients assigned to ticagrelor and 58 patients assigned to prasugrel in the overweight group (8.3% vs 6.2%; HR, 1.36; 95%CI, 0.97-1.91; P=.076), and 43 patients assigned to ticagrelor and 37 patients assigned to prasugrel in the obesity group (8.6% vs 7.3%; HR, 1.18; 95%CI, 0.76-1.84; P=.451). The 1-year incidence of bleeding events did not differ between ticagrelor and prasugrel in patients with normal weight (6.5% vs 6.6%; P=.990), overweight (5.6% vs 5.0%; P=.566) or obesity (4.4% vs 2.8%; P=.219). There was no significant treatment arm-by-BMI interaction regarding the primary endpoint (Pint=.578) or secondary endpoint (Pint=.596). Conclusions In patients with ACS, BMI did not significantly impact the treatment effect of ticagrelor vs prasugrel in terms of efficacy or safety (AU)

Distribution of angiographic measures of restenosis after drug-eluting stent implantation.

BACKGROUND: A bimodal distribution of measures of restenosis has been demonstrated at 6-8 months after bare metal stent implantation. Drug-eluting stent (DES) treatment has attenuated the impact of certain factors (eg, diabetes) on restenosis but its effect on the distribution of indices of restenosis is not known. OBJECTIVE: To perform a detailed analysis of the metrics of restenosis indices after DES implantation. Design, settings, PATIENTS: Prospective observational study of patients undergoing DES implantation (Cypher, sirolimus-eluting stent; or Taxus, paclitaxel-eluting stent) at two German centres, with repeat angiography scheduled at 6-8 months after coronary stenting. MAIN OUTCOME MEASURES: In-stent late luminal loss (LLL) and in-segment percentage diameter stenosis (%DS) as determined by quantitative coronary angiography at recatheterisation. RESULTS: Paired cineangiograms were available for 2057 patients. Overall mean (SD) LLL was 0.31 (0.50) mm; mean (SD) %DS was 30.3 (15.7)%. Distribution of both LLL and %DS differed significantly from normal (Kolmogorov-Smirnov test; p<0.001 for each). For both parameters a mixed distribution model better described the data (likelihood ratio test with 3df; p<0.001 for each). This consisted of two normally distributed subpopulations with means (SD) of 0.10 (0.25) mm and 0.69 (0.60) mm for LLL, and means (SD) of 22.2 (8.6)% and 40.1 (16.6)% for %DS. The results were consistent across subgroups of DES type, "on-label" versus "off-label" indication, and presence or absence of diabetes. CONCLUSIONS: LLL and %DS at follow-up angiography after DES implantation have a complex mixed distribution that may be accurately represented by a bimodal distribution model. The introduction of DES treatment has not resulted in elimination of a variable propensity to restenosis among subpopulations of patients with stented lesions.

Pre-procedural C-reactive protein levels and clinical outcomes after percutaneous coronary interventions with and without abciximab: pooled analysis of four ISAR trials.

OBJECTIVE: To assess the prognostic value of the baseline C-reactive protein (CRP) level in patients undergoing percutaneous coronary intervention (PCI) after pre-treatment with 600 mg of clopidogrel and whether there is an interaction between CRP level and abciximab in terms of outcome. DESIGN: Pooled analysis from the ISAR-SWEET, SMART-2, ISAR-REACT and REACT-2 trials. SETTING, METHODS: The study included 4847 patients with coronary artery disease (CAD) undergoing PCI after pre-treatment with 600 mg of clopidogrel. The primary outcome was one-year mortality. The combined incidence of death, myocardial infarction and target lesion revascularisation was the secondary outcome. RESULTS: Based on the median value of CRP (2.3 mg/l), patients were divided into two groups: the high-CRP group (n = 2448) and the low-CRP group (n = 2399). During one year, there were 141 deaths (5.8%) in the high-CRP group compared with 51 deaths (2.1%) in the low-CRP group (OR = 2.77, 95% CI 2.04 to 3.77; p<0.001). The incidence of major adverse cardiac events (MACE) was 28% in the high-CRP group compared with 25% in the low-CRP group (OR = 1.13, 95% CI 1.01 to 1.26; p = 0.034). The Cox proportional hazards model showed that high CRP was an independent predictor of one-year mortality (hazard ratio 2.20, 95% CI 1.54 to 3.15; p<0.001 for CRP level >2.3 mg/l vs CRP level < or =2.3 mg/l). No significant interaction was observed between CRP level and abciximab regarding one-year mortality (p = 0.08) or MACE (p = 0.68). CONCLUSION: In patients with CAD undergoing PCI after pretreatment with 600 mg of clopidogrel, baseline CRP level predicts one-year mortality and MACE. Abciximab therapy did not confer any particular beneficial effect in patients with a higher inflammatory burden.

Left and right ventricular diastolic functions in patients with rheumatoid arthritis without clinically evident cardiovascular disease.

The aim of this study was to assess the prevalence of diastolic dysfunction of the left ventricle (LV) and of the right ventricle in patients with rheumatoid arthritis (RA) without clinically evident cardiovascular manifestations and to estimate whether there is a correlation between the duration of RA and the degree of LV diastolic dysfunction. The study included 81 patients (61 females and 20 males) with RA without clinically evident heart disease (group 1) and 40 healthy subjects (29 females and 11 males) who served as a control group (group 2). Both groups were matched for age and sex. Echocardiographic and Doppler studies were conducted in all patients with RA and control subjects. There were significant differences between patients with RA vs. control group with regard to early diastolic flow velocity (E), atrial flow velocity (A) and the E/A ratio (0.68 +/- 0.19 m/s vs. 0.84 +/- 0.14 m/s, p < 0.001; 0.73 +/- 0.15 m/s vs. 0.66 +/- 0.13 cm/s, p = 0.01; and 0.97 +/- 0.3 vs. 1.32 +/- 0.37, p < 0.001, respectively). There was significant difference between groups regarding the right ventricular early diastolic (Er)/atrial (Ar) flow velocities (Er/Ar ratio) (1.07 +/- 0.3 vs. 1.26 +/- 0.3, p = 0.002). There was a weak correlation between transmitral E/A ratio and the duration of RA (r = - 0.22, p = 0.001). Myocardial performance index (MPI) appeared to differ little in patients with RA as compared with control group (0.51 +/- 0.1 vs. 0.52 +/- 0.2, p = NS). In patients with RA without clinically evident cardiovascular disease, the left ventricular diastolic function and the right ventricular diastolic function are reduced. Left ventricular wall thickness, dimensions, systolic function and MPI were found to be normal. LV diastolic function had a weak correlation with the duration of RA.

Reentry circuit location and left atrial three-dimensional activation patterns in left atrial flutter.

We report the case of a patient with left atrial flutter (LAF) in whom the reentry circuit location was mapped with a 64-electrode basket catheter deployed in the left atrium. Left atrial three-dimensional activation patterns were constructed with a software program and presented as color-coded isochrones. The reentrant activation traveled preferentially around the mitral annulus in a clockwise direction. It consisted of a single reentry confined anteriorly by the mitral annulus and posteriorly by an anatomic-functional barrier composed of a functional conduction block extending between pulmonary veins and surrounding a part of the posterior wall of the left atrium. The lower portion of the posterior wall and the anterior wall in close proximity to mitral annulus were preferentially used by the reentrant impulse.

The diagnostic significance of real sinus node automaticity depression in symptomatic sinus bradycardia.

Atrial overdrive pacing was performed, before and after autonomic blockade, in 42 consecutive patients (32 males and 10 females, mean age 46 +/- 11 years) with symptomatic sinus bradycardia. Patients were divided into two groups: Group I, 23 patients (mean age 43 +/- 8 years) with normal intrinsic heart rate (IHR) and normal intrinsic corrected sinus node recovery time (intrinsic CSNRT < 425 ms) and Group II, 19 patients (mean age 49 +/- 13 years) with abnormal intrinsic sinus node automaticity identified after autonomic blockade by abnormal IHR and/or by abnormal intrinsic CSNRT (> 425 ms). In addition to sinus cycle length, IHR, maximal CSNRT and sinoatrial conduction time (SACT) the real sinus node automaticity depression (SAD) was also evaluated, calculated after autonomic blockade (intrinsic CSNRT-SACT). Not all patients with an abnormal IHR showed abnormally prolonged CSNRT and not all patients with normal IHR had normal CSNRT. Among Group I (normal IHR) in 19 patients the real SAD was < 300 ms, while among Group II in 8 of 11 patients showing abnormal IHR the real SAD was > 300 ms. The abnormal value of SAD (> 300 ms) observed not only in patients with abnormal IHR and/or abnormally prolonged intrinsic CSNRT but also in several patients with normal IHR, increases the sensitivity of testing and may allow to detect even latent organic sinus node dysfunction. In conclusion, a synopsis of IHR, intrinsic CSNRT and intrinsic SACT with real SAD may be useful to estimate more accurately the degree of the impairment of intrinsic sinus node automaticity helping to differentiate the organic sinus node dysfunction from the autonomic one.