Efficacy of coronary angioplasty following conventional coronary thrombolysis in patients with acute myocardial infarction.

The efficacy of combined thrombolysis and angioplasty for the purpose of coronary reperfusion after acute myocardial infarction has been controversial. The present study was conducted, therefore, to evaluate the effects of angioplasty following administration of conventional thrombolytic agents on the long-term prognosis of acute myocardial infarction patients. A total of 409 patients admitted to the hospital within 12 hours of the onset of infarction between January 1990 and May 2001 were studied retrospectively. These included 151 patients treated with thrombolysis alone (group T), 73 patients treated with angioplasty alone (group A), and 35 patients treated with angioplasty after thrombolysis (group T&A). Group T&A had shorter intervals from onset to initial treatment than group A (3.0 hours vs 6.3 hours, p < 0.01), a higher reperfusion success rate than group T (91.4% vs 74.8%, p < 0.01), and more improved left ventricular wall motion than group A. One-year cardiac mortality rates tended to be higher in group T, which had a higher rate of unsuccessful reperfusion than groups T&A or A (8.1% vs 3.4% vs 3.5%). The frequencies of hemorrhagic complications were similar among the 3 groups. From these findings, we conclude that thrombolytic therapy with subsequent angioplasty is an effective strategy for achieving cardiac reperfusion following acute myocardial infarction.

Calcium antagonists for secondary prevention of myocardial infarction: is there a need to shift from short-acting to long-acting types?

BACKGROUND: Although short-acting nifedipine does not prevent myocardial infarction (MI), calcium antagonists with a long half-life may be effective. METHODS AND RESULTS: The present study was a retrospective analysis of the incidences of cardiac events among patients with a healed MI treated with 3 times-a-day type nifedipine (half-life 1.8 h; n=617), twice-a-day type nifedipine (half-life 4.0 h; n=527) and those not taking calcium antagonists (n=1,593) from 1986 to 1993, and the incidences of those on once-a-day type calcium antagonists (half-life 11.0 h; n=903) and those not taking calcium antagonists (n=2,788) from 1994 to 2001. Cardiac events included cardiac death and nonfatal recurrent MI. Single and multivariate analyses using the Cox-Hazard model were performed. From 1986 to 1993 cardiac events occurred in 38 patients with 3-times-a-day nifedipine (6.2%, hazard ratio and 95% confidence interval: 1.45 and 0.93-2.27), in 18 patients with twice-a-day nifedipine (3.4%: 0.68 and 0.39-1.20), 57 patients without calcium antagonists (3.6%). Cardiac events also occurred in 11 patients with once-a-day type nifedipine (1.2%: 0.72 and 0.37-1.42) and 48 patients without calcium antagonists (1.7%). Of the once-a-day type calcium antagonists, cardiac events were the lowest (2 patients, 0.6%: 0.32 and 0.08-1.31) in patients with amlodipine (half-life 39.0 h; n=334), which has the longest half-life. None of these drugs were a significant factor in the increase or decrease in the incidence of cardiac events. However, there was a good correlation between the half-life of the calcium antagonist and the hazard ratio for reducing cardiac events. CONCLUSION: Although there was a tendency toward a reduction in cardiac events using calcium antagonists with long half-life, none of these drugs could significantly reduce the incidence of cardiac events in patients with a healed MI.

Unilateral renal hypoplasia associated with bicuspid aortic valve.

A 20-year-old man with congestive heart failure (CHF) and hypertension (HT) was admitted to hospital. Ultrasonic echocardiography showed that he had aortic stenosis caused by a bicuspid aortic valve. The plasma renin concentration was slightly elevated, and enhanced magnetic resonance imaging and renography revealed a hypoplastic kidney that had almost lost its normal function. It is postulated that the increased afterload and preload of the left ventricle induced by both of these abnormalities contributed to the onset of CHF and HT. Pharmacological therapy alone failed to control the CHF and HT, but surgical removal of the hypoplastic kidney was effective in reducing the plasma renin concentration and treating the CHF and HT.

Modification of treatment strategies over a period of 14 years has markedly reduced cardiac events among post-myocardial infarction patients.

Recent trends in the treatment of post-myocardial infarction (MI) patients and the factors accounting for the improvement in outcome are presented. A total of 6,602 post-MI patients (5,320 males, 1,282 females; 58.9 +/- 10.4 years of age) enrolled between 1986 and 1999 were followed up for an average of 12.6 +/- 16.3 months. The incidence of cardiac events, which included fatal and nonfatal recurrent MIs, sudden death and death by congestive heart failure, was highest (44.9 events/1,000 person year) in 1986-1987, but decreased steadily to 22.5 events/1,000 person year by 1997-1999 (Trend p<0.0001). This trend accompanied the increased use of coronary thrombolysis, percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery, increased prescription of antiplatelet agents (51.5%-83.4%), lipid-lowering agents (29.8%-52.6%) and angiotensin-converting enzyme inhibitors (5.3%-->41.0%), and reduced prescription of calcium antagonists (68.5%-41.0%) and nitrates (60.7%-->45.7%). These changes in treatment have led to a decreased incidence of angina pectoris, wall motion abnormalities and abnormal Q waves on electrocardiograms. The decline in the incidence of cardiac events among post-MI patients in the 14 years between 1986 and 1999 reflects implementation of new therapeutic modalities proven to be effective in clinical trials and in daily practice.