Sudden Cardiac Death in Patients With Ischemic Heart Failure Undergoing Coronary Artery Bypass Grafting: Results From the STICH Randomized Clinical Trial (Surgical Treatment for Ischemic Heart Failure).

BACKGROUND: The risk of sudden cardiac death (SCD) in patients with heart failure after coronary artery bypass graft surgery (CABG) has not been examined in a contemporary clinical trial of surgical revascularization. This analysis describes the incidence, timing, and clinical predictors of SCD after CABG. METHODS: Patients enrolled in the STICH trial (Surgical Treatment of Ischemic Heart Failure) who underwent CABG with or without surgical ventricular reconstruction were included. We excluded patients with prior implantable cardioverter-defibrillator and those randomized only to medical therapy. The primary outcome was SCD as adjudicated by a blinded committee. A Cox model was used to examine and identify predictors of SCD. The Fine and Gray method was used to estimate the incidence of SCD accounting for the competing risk of other deaths. RESULTS: Over a median follow-up of 46 months, 113 of 1411 patients who received CABG without (n = 934) or with (n = 477) surgical ventricular reconstruction had SCD; 311 died of other causes. The mean left ventricular ejection fraction at enrollment was 28±9%. The 5-year cumulative incidence of SCD was 8.5%. Patients who had SCD and those who did not die were younger and had fewer comorbid conditions than did those who died of causes other than SCD. In the first 30 days after CABG, SCD (n=5) accounted for 7% of all deaths. The numerically greatest monthly rate of SCD was in the 31- to 90-day time period. In a multivariable analysis including baseline demographics, risk factors, coronary anatomy, and left ventricular function, end-systolic volume index and B-type natriuretic peptide were most strongly associated with SCD. CONCLUSIONS: The monthly risk of SCD shortly after CABG among patients with a low left ventricular ejection fraction is highest between the first and third months, suggesting that risk stratification for SCD should occur early in the postoperative period, particularly in patients with increased preoperative end-systolic volume index or B-type natriuretic peptide. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT0002359.

In-Hospital Outcomes after Rescue Percutaneous Coronary Intervention in Patients with ST Segment Elevation Myocardial Infarction.

Objective: To investigate the outcomes of patients who underwent rescue percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) after failed thrombolytic therapy. Material and Method: This observational cohort study was conducted between June 1, 2008 and May 31, 2013. Consecutive STEMI patients who underwent either emergency rescue PCI or primary PCI were included. Rescue PCI patients were compared with primary PCI patients. Clinical data including baseline characteristics, angiographic results, periprocedural details, and in-hospital adverse events were reviewed. Results: Three hundred sixteen patients were enrolled, of which 72.5% were male. Mean age of participants was 59.5 years. Rescue PCI and primary PCI was performed in 24 and 292 patients, respectively. Median time from symptom onset to emergency room (ER) arrival was 175 minutes and not statistically different between groups. Thirteen percent of patients were critically ill and in cardiogenic shock upon arrival. Radial artery access was significantly more frequently used in the rescue PCI group. The rescue PCI group had a significantly higher proportion of initial TIMI grade 3 flow than the primary PCI group (rescue PCI 33.3% vs. primary PCI 13.4%, p = 0.042). No significant differences were observed in final TIMI grade 3 between the two groups (rescue PCI 87.5% vs. primary PCI 89.7%, p = 0.77). Rate of platelet glycoprotein IIb/IIIa receptor blocker use was significantly higher in the primary PCI group (41.4% vs. 4.2%, p<0.001). Left ventricular ejection fraction was significantly higher in the rescue PCI group (rescue PCI 57.7% vs. primary PCI 50%, p = 0.013). There were no significant differences between groups for angiographic success rate (rescue PCI 83.3% vs. primary PCI 88.7%, p = 0.229) or procedural success rate (rescue PCI 79.2% vs. primary PCI 85.6%, p = 0.164). Forty-one patients (14%) in primary PCI group and two patients (8.3%) in rescue PCI group died during hospitalization (p = 0.75). Stroke and reinfarction were rare events in this study. Hemorrhagic stroke occurred in one patient in each group. There were no significant differences in major bleeding or major vascular complications between groups. Conclusion: The angiographic outcome and procedural success rates in patients who underwent rescue PCI were not significantly different from rates in patients who underwent primary PCI. Rescue PCI in STEMI can be performed with favorable success rates and in-hospital outcomes and should be considered in patients that experience failure after thrombolytic therapy.

Differentiation of Takotsubo Cardiomyopathy from ST Elevation Myocardial Infarction in Patients Activated for Fast-Track Coronary Angiography.

Objective: To compare clinical and electrocardiographic (ECG) features between Takotsubo cardiomyopathy (TC) and ST-elevation myocardial infarction (STEMI). Material and Method: We retrospectively reviewed clinical, electrocardiographic, and laboratory features of 20 consecutive TC patients and 155 consecutive STEMI patients who were activated for fast-track coronary angiography and were ultimately diagnosed with either TC or STEMI and compared these data between the two groups. Results: Patients with TC were older (p = 0.001), more often female (p = 0.001), had more often been triggered by intense emotional or physical stress (p = 0.001) or illness (p = 0.001), and had a lower rate of smoking (p = 0.005) than STEMI patients. Compared with patients who presented with anterior wall STEMI, those with TC less commonly had Q waves (30.0% vs. 62.9%, p = 0.007) and reciprocal change (0.0% vs. 37.1%, p = 0.001), and had a lower rate of ST-segment elevation in lead V1 (5.0% vs. 59.8%, p = 0.001). ST-segment depression was also more common in TC in lead aVR (20.0% vs. 2.1%, p = 0.008). Previously proposed ECG criteria had low sensitivity, but high specificity in our patients. Our proposed point scoring model includes the use of both clinical and ECG findings. According to our proposed model, a score ≥4 had 90% sensitivity and 98% specificity in differentiating TC from acute anterior STEMI (AUC = 0.976, p<0.001). Conclusion: In patients activated for fast-track coronary angiography because of acute coronary ST-segment elevation syndrome, a number of clinical and ECG features differ between TC patients and patients with true STEMI. Our proposed point scoring model that uses clinical and ECG findings demonstrated improved diagnostic accuracy in differentiating TC from acute anterior STEMI.

Achievement of LDL-cholesterol goal with statins after an st segment elevation myocardial infarction.

BACKGROUND: In patients with very high cardiovascular risk, low-density lipoprotein cholesterol (LDL-C) less than 70 mg/dL or at least 50% reduction of LDL-C are recommended targets. High-dose atorvastatin has been shown to reduce death and ischemic events among patients with acute coronary syndrome. OBJECTIVE: To evaluate the proportion of STEMl patients that achieve LDL-C goal after hospital discharge from a real-world setting in Thailand To determine if the formulation of statin prescribed affected the LDL-C goal achievement. MATERIAL AND METHOD: The authors analyzed data from a cohort of patients with STEMI enrolled from June 1, 2008 through May 31, 2011. Patients who survived, were prescribed astatin on discharge and had LDL-C data at follow-up were analyzed. The formulation of statin was categorized as simvastatin or other statins (atorvastatin or rosuvastatin) group. RESULTS: Ninety-seven percent (n = 265 of 272) of patients were prescribed a statin at discharge. Of these, 216 patients had LDL-C data during a 3-month follow-up period, 75% were men, the mean age was 60.5 ± 12.2 years old and the mean baseline LDL-C was 118.1 ± 41.2 mg/dL. 73% (n = 157) of patients received simvastatin and 27% (n = 59) received other statins. At discharge, the median daily dose of simvastatin, atorvastatin and rosuvastatin were 20, 20 and 10 mg respectively. At follow-up, target LDL-C < 70 mg/dL or LDL-C reduction ≥ 50% was achieved in 30.1% (n = 65) of patients, 27.4% (n = 43) on simvastatin and 37.3% (n = 22) on other statins, (p = 0.158, simvastatin versus other statins). When stratified by the dose intensity of statin, a significantly greater proportion of patients on moderate to high intensity statin attained LDL-C goals than those on low intensity statin: (36.3% versus 24.3%, p = 0.038). CONCLUSION: Most patients with STEMI are prescribed statin therapy at discharge. Despite this, the target LDL-C is attained in a minority of the patients due to suboptimal statin dosing. The formulation of statin did not affect LDL-C goal attainment. High-dose statin therapy is underused in real-world clinical practice. These findings emphasize the opportunities to improve outcomes of STEMI patients with evidence-based therapies.

Predictors of in-hospital adverse events after PCI for NSTEMI in the National Percutaneous Coronary Intervention (PCI) Registry.

OBJECTIVE: Evaluate the in-hospital major adverse cardiovascular events (MACE) and clinical predictors of non-ST-T Mt that undergoing percutaneous coronary interventions (PCI) in Thailand. MATERIAL AND METHOD: Thailand National PCI Registry enrolled 4156 patients that underwent PCI in Thailand between May 1 and October 31, 2006. Four hundred eighty three patients underwent PCI with indication of non-ST-T MI. Baseline demographic and angiographic characteristic were recorded. MACE included CV death, M, and stroke. RESULTS: In-hospital MACE occurred in 27 patients (5.6%), included CV death in 15 patients (3.1%), MI in 14 patients (2.9%), and stroke in 2 patients (0.4%). In-hospital MACE were higher in patients with previous history of CABG (19.2% versus 4.8%, p = 0.01), cardiogenic shock at presentation (29.3% versus 3.4%, p<0.001), significant left main disease (19.4% versus 4.6%, p = 0.005), baseline ejection fraction <30% (25% versus 4.4%, p = 0.003), and used of intra-aortic balloon counter pulsation (IABP) during PCI (26.3% versus 3.8%, p<0.001). After multiple logistic regression analysis, prior history of CABG (OR = 6.1, 95% CI: 1.1-32.4, p = 0.03), baseline ejection fraction <30% (OR = 6.5, 95% CI: 1.7-24.4, p = 0.005), and used of lABP during PCI (OR = 4.7, 95% CI: 1.3-16.8, p = 0.01) are the strongest predictors of in-hospital MACE. CONCLUSION: In the National Thai PCI Registry, patients with non-ST-T MI undergoing PCI had in-hospital major adverse events rate at 5.6%. Prior CABG, low EF <30%, unstable hemodynamic required used of lABP during PCI and procedure scheduled as an urgent or emergent were predictors of in-hospital MACE.

First medical contact to device time in the Thailand percutaneous coronary intervention (PCI) registry.

OBJECTIVE: The aim of this study is to evaluate the first medical contact (FMC) to device time in the Thai national PCI registry 2006, and its effect on the clinical outcome. MATERIAL AND METHOD: Thailand national PCI registry enrolled 4,156 patients who underwent PCI from the all catheterization laboratories in Thailand between May 1st and October 31st, 2006. RESULTS: 581 patients with acute myocardial infarction (AMI), 352 patients underwent primary angioplasty, 229 patients underwent rescue angioplasty/facilitated PCI or after successful thrombolytic. Median FMC.to device time in primary angioplasty group was 115 minutes (range 24-1335 minutes); only 29.8% of patients who able to achieve FMC to device time ≤ 90 minutes. Cardiogenic shock was significant lower if FMC to device time ≤ 90 minutes (2.1% (1/48) versus 12.4% (14/113) if FMC to device time > 90, p = 0.040). In-hospital mortality occurred for 4.8% (2/48) ifFMC to device time ≤ 90 minutes and was 8.8% (10/113) if FMC to device time > 90 minutes, p = 0.510). Death occurred in 4.2% (2/48) if FMC to device time ≤ 90 minutes, 6.3% (5/79) if FMC to device time between 91-180 minutes, 6.7% (1/15) if FMC to device time between 181-270 minutes, 42.9% (3/7) if FMC to device time between 271-360 minutes and 8.3% (1/12) if FMC to device time > 360 minutes, (p = 0.040). CONCLUSION: FMC to device time is strongly associated with the risk ofcardiogenic shock and mortality. In Thailand national PCI registry in 2006, the majority of the patients did not receive primary PCI in timely fashion.

One-year clinical outcomes of ST segment elevation myocardial infarction patients treated with emergent percutaneous coronary intervention: the impact of thrombus burden.

OBJECTIVE: To investigate the impact of thrombus burden on 1-year clinical outcomes in patients who underwent emergent percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). MATERIAL AND METHOD: Angiographic evidence of intracoronary thrombus adversely affects the outcome of PCI in STEMI. Large thrombus burden (> or = 2 times vessel diameter) has been shown to be a significant predictor of major adverse cardiac events (MACE). The impact of thrombus burden in Asian patients who undergo PCI in STEMI has not been described. This is an observational cohort of patients with STEMI from June 1, 2008 through May 31, 2011, who underwent emergent PCI (primary or rescue). The patients were categorized into two groups according to the angiographic thrombus burden, large thrombus burden (> or = 2X vessel diameter size, LTB) and small thrombus burden (< 2X vessel diameter size, STB). MACE was defined as the composite of death, repeat myocardial infarction, target vessel revascularization and stent thrombosis. RESULTS: 202 patients were enrolled, 72% were male and the mean age was 60 years old. 134 patients (66%) presented with an occluded infarct related artery. Primary PCI was performed in 90.6% of the patients and the remainder underwent rescue PCI. One hundred eleven (55%) patients were categorized into the STB group and 91 patients (45%) into the LTB group. The use of aspiration thrombectomy was significant higher in the LTB group (LTB 80.2% vs. STB 60.44%, p = 0.002). A higher proportion of patients in the STB group underwent direct stenting strategy (STB 32.4% vs. LTB 18.7%, p = 0.027). There were no significant differences in final TIMI grade 3 flows and procedural success between the groups. Overall, in hospital, mortality was 13.4% and there were no significant differences among the groups. At 1-year follow-up, there was no significant difference in cumulative MACE-free survival in the LTB vs. STB group (82.4% vs. 79.3%, 95% confidence interval for the difference: -8.0% to 13.8%, p = 0.59). CONCLUSION: In the current study, large thrombus burden is not an independent predictor of 1-year cumulative MACE in STEMI patients who were treated with emergent PCI.

Validation of the GRACE risk score to predict in-hospital mortality in patients with ST segment elevation myocardial infarction in Thailand.

BACKGROUND: The GRACE risk score (GRS) is a validated risk score to predict mortality in acute coronary syndrome patients. However, data on the use of the GRS in Asian patients are limited. The authors assessed the validity of this risk score in a contemporary cohort of patients with ST segment elevation myocardial infarction (STEMI) admitted to a tertiary care hospital in Thailand. MATERIAL AND METHOD: From June 1, 2008 through May 31, 2010, 209 consecutive patients with STEMI were prospectively enrolled. The GRS was calculated for each patient. Patients were stratified into three GRACE risk tertiles: high, intermediate and low risk groups. In-hospital mortality rate was assessed and compared to the GRS predicted mortality. RESULTS: The mean GRS was 161 +/- 46.2 and the overall in-hospital mortality was 12.4%. Using the GRS, 103 (49.3%) patients were stratified to the high-risk group (> or = 155 points), 59 (28.20%) patients to the intermediate-risk group (126-154 points) and 47 (22.50%) patients to the low-risk group (< or = 125 points). The observed in-hospital mortality rate was 23.3% (95% CI 16.2-32.3) in the high-risk group and 3.4% (95% CI 0.94-11.5) in the intermediate-risk group. None of the patients in the low risk group died, 0% (95% CI 0-7.9) (p < 0.001, low risk vs. high risk; p = 0.001 intermediate risk vs. high risk) CONCLUSION: Use of the GRS in STEMI patients for predicting in-hospital mortality was validated. At the author's institute, the GRS is a useful tool to predict in-hospital death in STEMI patients.

High on-clopidogrel treatment platelet reactivity in Thai patients with chronic stable angina scheduled for percutaneous coronary intervention.

OBJECTIVE: To determine the prevalence, clinical profile, and risk factors of high on-clopidogrel treatment platelet reactivity in Thai patients with chronic stable angina scheduled for percutaneous coronary intervention. MATERIAL AND METHOD: The patients were prospectively recruited from the consecutive patients undergoing coronary angiography and planned for elective percutaneous coronary intervention (PCI). Ten ml of blood samples were cautiously drawn from the antecubital vein of the patients to determine the hemoglobin and platelet count. Platelet aggregation test was performed by light transmittance aggregometry using platelet-rich plasma. Platelets were stimulated with 5 microM adenosine diphosphate (ADP). Platelet aggregation was expressed as the maximal percent change in light transmittance from baseline. High on-clopidogrel treatment platelet reactivity was defined as post treatment maximal platelet aggregation > 46% with 5 micromol/l ADP used as agonist. RESULTS: The present study consecutively enrolled two hundred four patients diagnosed with chronic stable angina planned for PCI. Seventy-nine patients demonstrated the high on-clopidogrel treatment platelet reactivity (38.7%). Among these patients, 48% were men with a mean age of 66 years. Diabetes mellitus and chronic kidney disease were detected in 34.2%. Original clopidogrel (Plavix) was prescribed in 72% of the patients and 28% received generic clopidogrel (Apolets). The prevalence of high on-clopidogrel treatment platelet reactivity increased in the older patients, patients with CKD and patients receiving angiotensin receptor blockers (ARB). However from multivariate analysis, none of the risk factors, including age, BMl, diabetes mellitus, smoking, CKD, ARB use, and type of clopidogrel (Plavix versus Apolets) had a statistically significant association with the high on-clopidogrel treatment platelet reactivity. CONCLUSION: The prevalence of high on-clopidogrel treatment platelet reactivity in the present study was 38.7%. No significant association was demonstrated between age, BMI, diabetes mellitus, smoking, CKD, ARB use, type of clopidogrel, and high on-clopidogrel treatment platelet reactivity.

Aspirin resistance in Thai patients with chronic stable angina.

OBJECTIVE: To determine the prevalence, clinical profile and risk factors of aspirin resistance in Thai patients with chronic stable angina. MATERIAL AND METHOD: The patients were prospectively recruited from the consecutive patients diagnosed chronic stable angina at Siriraj Hospital during March 2011 to February 2012. Ten milliliter of blood samples were cautiously drawn from the antecubital vein of the patients to determine the hemoglobin, platelet count and platelet aggregation test performed by light transmittance aggregometry using platelet-rich plasma. Platelets were stimulated with 0.5 mg/ml of arachidonic acid and 10 mM adenosine diphosphate. Platelet aggregation was expressed as the maximal percent change in light transmittance from baseline. Aspirin resistance was defined as the mean platelet aggregation of > or = 70% with 10 mM ADP and the mean platelet aggregation of > or = 20% with 0.5 mg/ml of arachidonic acid. RESULTS: One-hundred and fifty seven patients diagnosed chronic stable angina were enrolled in the present study. There were 34 patients (21.6%) demonstrating aspirin resistance. The clinical characteristic of these patients included male 58.8% with mean age of 66 years, body mass index 27.5 kg/m2, diabetes mellitus 52.9%, smoking 8.8%, hypercholesterolemia 70.6% and proton pump inhibitor use 23.5%. Multivariate analysis demonstrated none of the risk factors including age, female, body mass index, diabetes mellitus, hypercholesterolemia, smoking and proton pump inhibitor (PPI) use had a statistically significant association with aspirin resistance. CONCLUSION: Our study demonstrated that the prevalence of aspirin resistance in Thai patients with chronic stable angina was 21.6%. No significant association was demonstrated between age, female, body mass index, diabetes mellitus, hypercholesterolemia, smoking, proton pump inhibitor (PPI) use and aspirin resistance.

Utilizing a registry for ST segment elevation myocardial infarction from a tertiary care hospital in Thailand: opportunities to improve the quality of care.

BACKGROUND: Treatment of acute coronary syndrome requires a reliable measurement of quality for ensuring evidence-based care. Clinical registries have been used to support quality improvement activities in some countries, but there are few data concerning their implementation in developing countries. In 2008, a multidisciplinary Siriraj ST segment elevation myocardial infarction (STEMI) registry team was formed with the intention to improve the process of care. This report summarizes observational data collected within the first year to characterize the clinical profile, management and in-hospital outcomes of STEMI patients at the author's institute. MATERIAL AND METHOD: The present study is a prospective, observational study. From June 2008 through June 2009, data from all consecutive patients presenting within 24 hours of STEMI at Siriraj Hospital were collected. The patient's data on demographics, procedures, medications and in-hospital outcomes were collected. RESULTS: During the 1-year period, 112 patients with STEMI were enrolled. The mean age was 59.3 years old and 81.3% were males. There was a high prevalence of diabetes, hypertension, dyslipidemia and current smoking. Median time from symptom onset to presentation was 120 minutes. 98 patients (84.8% of the patients) received reperfusion therapy in the form of thrombolytic therapy (21.4%) or primary percutaneous coronary intervention (PCI, 63.40%). For thrombolytic therapy, the median door to needle time was 68 minutes. Rescue PCI was performed in 20.8% of the thrombolytic treated patients. For primary PCI, the median door to balloon time was 118 minutes. In-hospital coronary artery bypass graft surgery was performed in 6% of the patients. In-hospital mortality rate was 9.8%. Re-infarction and stroke were rare events. CONCLUSION: Despite a high utilization rate of reperfusion therapy the time to reperfusion therapy exceeds the length of time recommended by current guidelines. The authors' findings provide important data for future benchmarking and represent a significant opportunity for quality improvement in STEMI-related care and outcomes.

Clinical Outcomes of Rotational Atherectomy in Heavily Calcified Lesions: Evidence From the Largest Cardiac Center in Thailand.

Background: Evidence regarding the clinical outcomes of rotational atherectomy (RA) in middle-income countries is limited. We analyzed the clinical outcomes of patients with heavily calcified coronary lesions who underwent RA-assisted percutaneous coronary intervention (PCI) and explored the risks for developing major adverse cardiovascular and cerebrovascular events (MACCE). Methods: This is a single-center, retrospective cohort analysis that enrolled consecutive patients who underwent RA-assisted PCI at the largest tertiary hospital in Thailand. The primary endpoint is the incidence of MACCE during the first-year follow-up. MACCE consists of cardiac death, ischemic stroke, definite stent thrombosis, target lesion revascularization, and target vessel revascularization. Results: From January 2015 to December 2018, 616 patients (663 lesions) were enrolled. The mean age was 72.8 ± 9.7 years, 292 (47.4%) patients were female and 523 (84.9%) completed one-year follow-up. Drug-eluting stents were deployed in 606 (91.4%) lesions. The RA success rate - defined as when the operator successfully passed the burr across the target lesion - was 99.4% and the angiographic success rate was 94.8%. 130 (21.4%) procedures developed periprocedural complications. The cumulative MACCE rate at 30-days was 1.5% and at 1-year was 6.3%. The in-hospital mortality rate was 1.1% and the cardiac death rate was 1.6%. Independent risk factors for developing MACCE included the use of an intra-aortic balloon pump (hazard ratio [HR] 3.96, 95% confidence interval [CI] 1.54-10.21; P = 0.004), a history coronary artery bypass graft (HR 2.30, 95% CI 1.01-5.25; P = 0.048), and increased serum creatinine (HR 1.16, 95% CI 1.04-1.30; P = 0.008). Conclusions: RA is an effective revascularization technique for heavily calcified lesions. This study demonstrates a high success rate and good short- to intermediate-term results of RA-assisted PCI in middle-income countries which are similar to high-income countries. Nevertheless, the rate of periprocedural complications remains high.

Intravascular Imaging Guidance Reduce 1-Year MACE in Patients Undergoing Rotablator Atherectomy-Assisted Drug-Eluting Stent Implantation.

Objectives: This study aimed to investigate the incidence of 1-year major adverse cardiac events (MACE) compared between intravascular imaging guidance and angiographic guidance in patients undergoing rotablator atherectomy (RA)-assisted percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Methods: This retrospective analysis included 265 consecutive patients with heavy calcified lesion who underwent RA-assisted PCI with DES implantation at our institution during the January 2016-December 2018 study period. This study was approved by the Siriraj Institutional Review Board. Patients were divided into either the angiographic guidance PCI group or the imaging guidance PCI group, which was defined as intravascular ultrasound or optical coherence tomography. The primary endpoint was 1-year MACE. Results: Two hundred and sixty-five patients were enrolled, including 188 patients in the intravascular imaging guidance group, and 77 patients in the angiographic guidance group. One-year MACE was significantly lower in the imaging guidance group compared to the angiographic guidance group (4.3 vs. 28.9%, respectively; odds ratio (OR): 9.06, 95% CI: 3.82-21.52; p < 0.001). The 1-year rates of all-cause death (OR: 8.19, 95% CI: 2.15-31.18; p = 0.002), myocardial infarction (MI) (OR: 6.13, 95% CI: 2.05-18.3; p = 0.001), and target vessel revascularization (TVR) (OR: 3.67, 95% CI: 1.13-11.96; p = 0.031) were also significantly lower in the imaging guidance group compared with the angiographic guidance group. The rate of stroke was non-significantly different between groups. Conclusion: In patients with heavy calcified lesion undergoing RA-assisted DES implantation, the intravascular imaging guidance significantly reduced the incidence of 1-year MACE, all-cause death, MI, and TVR compared to the angiographic guidance.

Evaluation of the firebird sirololimus eluting stent in all comers with coronary artery stenosis.

OBJECTIVE: Percutaneous coronary intervention (PCI) has been widely used to treat obstructive coronary artery disease. With the advent of drug-eluting stent (DES) in real world registry was proved as promising therapy. The limitation of the use of DES is the limited health care expenditure. We propose the use of Chinese made DES among Thai patients and that this will solve the cost issue. The clinical result of this DES has not been well known. METHODS: Prospective study from November 2005 to March 2007 using the structured registry form to evaluate the safety and efficacy of new Chinese made Firebird sirolimus eluting stent (Firebird SES) on clinical parameters from in-hospital, 30 days and 12 months or longer term follow-up. End point is major adverse cardiac event (MACE) including death, MI, TLR and CABG at 30 day and cumulative MACE at 12 month follow-up. RESULTS: Ninety consecutive patients who were treated with Firebird stent implantation (107 target lesions) were analyzed. Angiographic success (defined as < 30% diameter stenosis) was 85%. Procedure success was 77.8%. MACE at 30 day was 16.6%, cumulative MACE at 12 months was 18.8%. There were total 9 deaths during the study period, two deaths occurred at before 30 days, 3 deaths occurred before 12 months and other 4 deaths occurred after 12 months to 1305 days. Eighty patients (88.9%) had either office visit or telephone call follow-up after 12 months, 38 patients (42.2%) underwent clinical driven coronary arteriography, binary restenosis was 26.3%. Shock and smoking history was the analyzed predictor of MACE at follow-up. CONCLUSION: The implantation of Firebird DES in unselected patients (all comers) is safe, effective and could be an alternative choice of stent for Thai patients.

Early and intermediate outcomes of left main coronary intervention.

OBJECTIVE: We examined the immediate and long-term outcomes after stenting of all comers for left main coronary artery (LMCA) stenoses. BACKGROUND: Left main coronary artery disease is regarded as an absolute contraindication for coronary angioplasty. Recently, several reports on protected or unprotected LMCA stenting, or both, suggested the possibility of percutaneous intervention for this prohibited area. MATERIAL AND METHOD: Eighty-one consecutive patients with LMCA stenoses were treated with stents. The post-stent antithrombotic regimens were aspirin and clopidogrel. The major adverse cardiac events (MACE) including death, Q-wave myocardial infarction, or repeat target lesion revascularization were followed. Patients were followed very closely and all attended office visit at 12 months. RESULTS: The procedural success rate was 86.4%, with no episodes of acute thrombosis. Follow-up angiography was performed in 30 of 65 eligible patients (46.2%). Angiographic restenosis occurred in eight patients (9.9%). Cumulative death occurred in 16 patients (19.7%). MACE at 30 day and 12-month was 12.3% and 33.3% respectively. From multivariate analysis, dialysis (HR =3.22, p = 0.048), urgent PCI (HR =2.39, p = 0.036), post-procedure TIMI flow < 3 (HR =25.99, p = 0.001) and final kissing balloon inflation (HR = 0.30, p = 0.04) were independent predictors of MACE at 12-month. There was one definite late stent thrombosis (1.2%). CONCLUSION: Stenting of LMCA stenosis may be a safe and effective alternative to CABG in carefully selected patients. Further studies in larger patient populations are needed to assess late outcome.

Door-to-balloon time and factors associated with delayed door-to-balloon time in ST-segment elevation myocardial infarction at Thailand's largest tertiary referral centre.

OBJECTIVE: To analyse door-to-balloon (DTB) time and to identify factors significantly associated with delayed DTB in patients with ST-segment elevation myocardial infarction (STEMI) at Thailand's largest tertiary referral centre. BACKGROUND: DTB time is considered an important measure of performance quality. METHODS: This observational study analysed DTB time in patients with STEMI who presented to our institute's emergency department and underwent primary percutaneous coronary intervention (PCI) during June 2008 to May 2011. DTB time greater than 90 minutes was considered delayed. Data were collected to determine which clinical variables were associated with delays. RESULTS: One hundred thirty-three patients were included. The mean age of patients was 61.1 ± 13.2 years, and 71.4% were male. Delayed DTB was observed in 70.7% of patients. Median DTB time was 117 (interquartile range [IQR], 86-168), 66 (IQR, 58-84), and 135 (IQR, 112-194) minutes in all patients, in nondelayed patients, and in delayed patients, respectively. Univariate analysis revealed triage to urgent care (P = 0.001) and presentation during on-call hours (P < 0.001) to be significantly associated with delayed DTB. Patients who were triaged to urgent care had a DTB time of 184 vs 105 minutes for triage to the emergency room. Patients who presented during on-call hours had a DTB time of 128 vs 86 minutes for work hour presentation. Presentation during on-call hours was the only significant predictor of DTB time >90 minutes in multivariate analysis (odds ratio [OR], 7.86; 95% confidence interval [CI], 3.39-18.22; P < 0.001). All patients that were triaged to urgent care were delayed; thus, association between urgent care triage and on-call hour service could not be determined. CONCLUSIONS: Delayed DTB time occurred in 70.7% of patients. Two key factors that significantly contributed to delayed DTB were patient mistriage to urgent care and presentation during on-call hours.

Six-minute walk distance after coronary artery bypass grafting compared with medical therapy in ischaemic cardiomyopathy.

Background: In patients with ischaemic left ventricular dysfunction, coronary artery bypass surgery (CABG) may decrease mortality, but it is not known whether CABG improves functional capacity. Objective: To determine whether CABG compared with medical therapy alone (MED) increases 6 min walk distance in patients with ischaemic left ventricular dysfunction and coronary artery disease amenable to revascularisation. Methods: The Surgical Treatment in Ischemic Heart disease trial randomised 1212 patients with ischaemic left ventricular dysfunction to CABG or MED. A 6 min walk distance test was performed both at baseline and at least one follow-up assessment at 4, 12, 24 and/or 36 months in 409 patients randomised to CABG and 466 to MED. Change in 6 min walk distance between baseline and follow-up were compared by treatment allocation. Results: 6 min walk distance at baseline for CABG was mean 340±117 m and for MED 339±118 m. Change in walk distance from baseline was similar for CABG and MED groups at 4 months (mean +38 vs +28 m), 12 months (+47 vs +36 m), 24 months (+31 vs +34 m) and 36 months (-7 vs +7 m), P>0.10 for all. Change in walk distance between CABG and MED groups over all assessments was also similar after adjusting for covariates and imputation for missing values (+8 m, 95% CI -7 to 23 m, P=0.29). Results were consistent for subgroups defined by angina, New York Heart Association class ≥3, left ventricular ejection fraction, baseline walk distance and geographic region. Conclusion: In patients with ischaemic left ventricular dysfunction CABG compared with MED alone is known to reduce mortality but is unlikely to result in a clinically significant improvement in functional capacity. Trial registration number: NCT00023595.

Primary percutaneous transluminal coronary intervention compared with intravenous thrombolysis in patients with ST segment elevation myocardial infarction.

BACKGROUND: Primary percutaneous transluminal coronary intervention (PCI) and thrombolytic therapy (TT) are alternative means of achieving reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI). OBJECTIVE: To compare the outcomes between both reperfusion strategies. The authors sought to compare in-hospital outcomes after PCI or TT for patients with acute STEMI. MATERIAL AND METHOD: From August 2002 through June 2004, data from all patients who received reperfusion therapy for acute STEMI were collected prospectively. The decision regarding type of reperfusion strategy was at the attending cardiologist's discretion. The patient's data on demographics, procedures, medications, and in-hospital outcomes were analyzed. RESULTS: From August 2002 through June 2004, 234 patients were admitted to the authors' institute with the diagnosis of acute STEMI. Of the 146 patients who received reperfusion therapy, 91 were treated with primary PCI and 55 received intravenous TT as the reperfusion modality. In the TT group, 51 (93%) patients received streptokinase and 11 (21.6%) underwent rescue angioplasty. The two groups had similar baseline characteristics. Both patient groups had frequent presence of diabetes (PCI 44.2% vs. TT 39.6%, p = 0. 6). Cardiogenic shock on admission was present in 11% of the PCI patients and 7.3% of the TT patients (p = ns). In-hospital mortality was not significantly different in the two groups (PCI 14.3% vs. TT 10. 9%, p = 0.56). In the TT group, there was a trend toward a higher rate of major bleeding (PCI 6.6% vs. TT 16.4%, p = 0.06) and stroke (PCI 2.2% vs. TT 7.3%, p = 0.13) complications without statistical significance. CONCLUSION: The present findings suggest that both PCI and TT are comparable alternative methods of reperfusion among STEMI patients in terms of in-hospital mortality. In certain subgroups that are at increased risk of bleeding or stroke, primary PCI may be the preferred treatment strategy.

Diabetes mellitus and non-ST elevation myocardial infarction in Thai ACS Registry.

OBJECTIVE: To describe differences in in-hospital morbidity and mortality, presenting characteristics and management practices of diabetic and non-diabetic patients with non-ST elevation myocardial infarction using data from Thai ACS registry. MATERIAL AND METHOD: Thai ACS registry is a multi-center prospective project of nationwide registration in Thailand. RESULTS: The present study consisted of 3,548 patients with non-ST elevation myocardial infarction from 17 hospitals in about a 3-year period. About 50% of the patients with diabetes were more often female, with a greater prevalence of hypertension and dyslipidemia. The diabetic group was at an increased risk for congestive heart failure (adjusted odds ratio 1.84) but not increased risk for cardiac arrhythmia, cardiac mortality, and in-hospital mortality. CONCLUSION: There was a very high prevalence of diabetes in non-ST elevation myocardial infarction from ThaiACS registry. These patients were at increased risk for congestive heart failure as index of hospitalization but were not at increased risk for in-hospital mortality when compared with patients without diabetes.

Acute coronary syndrome in young adults: the Thai ACS Registry.

BACKGROUND: There are few data regarding acute coronary syndrome (ACS) in young adults. ACS in young adults may have some characteristics that are different from those in older patients. OBJECTIVE: The purpose of the present study was to assess the frequency, risk factors, presenting symptoms, treatment, complications and in-hospital outcomes of young patients with ACS in Thailand compared with those of older patients. MATERIAL AND METHOD: From the Thai ACS registry database of 9,373 consecutive patients admitted to participating hospitals between August 1, 2002 and October 31, 2005, the authors divided patients into three age categories: < 45 years, 45-54 years and > 54 years. Risk factors, presenting symptoms, type ofACS, management, complications and in-hospital outcomes of the 3 age groups were analyzed. RESULTS: Young patients comprised of 5.8% (544 patients) of all ACS patients. Discharge diagnosis in the young group was ST segment elevation myocardial infarction (STEMI) in 67%, non-ST segment elevation myocardial infarction (NSTEMI) 20% and unstable angina 14%. The young patients were more likely to have an STEMI than their elder counterparts. Risk factors such as tobacco use and a family history were more frequent in the young patients, whereas diabetes and hypertension were less frequent. Importantly, 66% of the patients aged <45 years had a history of tobacco use. A higher percentage of the young patients underwent coronary angiography, percutaneous coronary intervention and received aspirin, thienopyridines, GP IIb/ IIIa antagonists, beta-blockers and statins. In STEMI patients, reperfusion therapy was given more frequently in the patients aged < 45 years. Younger patients had a lower in-hospital mortality rate, lower incidence of congestive heart failure and a shorter length of stay. Multivariable analysis of in-hospital mortality revealed that older age remained an independent predictor of death. CONCLUSION: In Thailand, 5.8% ofpatients with ACS are under the age of 45 years old. The frequency of risk factors in the young patients differs from those in their elderly counterparts. The current management and aggressive risk factor modification are quite good and the overall mortality is lower in young adults with ACS compared to their elder counterparts. Primary preventive measures aimed at preventing our youth from adopting tobacco use should be implemented nationally.