comparison of outcomes of routine early angiography versus delayed ischemia-guided angiography after thrombolytic therapy in ST segment-elevation myocardial infarction

Thrombolytic therapy continues to be the common treatment in acute ST elevation myocardial infarction in the majority of heart centers worldwide. However, thrombolytic therapy is associated with high re-occlusion and re-infarction rates. So, most patients now undergo early diagnostic angiography and possibly angioplasty of the culprit artery but the controversy about the timing of angiography after thrombolysis continues to remain unresolved. In this prospective cohort study, we compared the outcome of early invasive strategy versus delayed invasive approach in ST-elevation MI patients who had received successful thrombolytic therapy. Primary endpoint of the study was Major Adverse Cardiovascular Events or MACE [the combined rate of death, re-infarction, major bleeding and cerebrovasular events. Secondary endpoints were re-infarction and re-hospitalization rate. The study comprised 142 patients of which 87 had a routine angiography in less than 10 days of acute event and 55 underwent ischemia-guided angiography after 10 days of index event. Stenting of the culprit vessel was done in 60% of the routine angiography group and 63% of the ischemia-guided group. The patients were followed for 8.8 +/- 2.8 months after the index event. The primary endpoint occurred in 6.9% of routine angiography patients and 10.9% of the control group [P= 0.4]. The rate of re-infarction was significantly higher in the delayed invasive arm than routine early invasive arm [10.9% vs. 1.1, P:0.01],and mostly occurring before angiography. Routine angiography as soon as possible after thrombolysis can reduce re-infarction and was not associated with any increased risk of adverse events in our study

Plasma homocysteine level and its genotypes as a risk factor for coronary artery disease in patients undergoing coronary angiography

Hyperhomocysteinemia has recently been identified as a risk for coronary artery disease [CAD]. Some genetic variants such as C677T polymorphism are postulated in this regard. We studied the relation between hyperhomocysteinemia and the above genetic variant and the risk of CAD and also the number of involved vessels. In total, there were 90 patients: 45 with angiographically documented CAD and 45 with the clinical manifestations of CAD but negative angiography. The blood homocystein level was measured using the ELISA and C677T polymorphism using the PCR method. The homocystein level was significantly higher in the case group [p value=0.00], but it did not show any correlation between its level and the extent of CAD. The case group was more homozygote in C677T allele but again it had no relation to the extent of CAD. Hyperhomocysteinemia acts as a CAD risk factor and whilst its presence increases the risk, it does not predict the extent of it

In-hospital course of early invasive strategy in acute coronary syndromes

Unstable angina is emerging as a major public health problem worldwide. Two approaches - an early invasive strategy or a conservative strategy - are used of the management of non-ST elevation acute coronary syndrome [MSTE-ACS]. An early invasive strategy involves the use of early coronary angiography and revascularization with percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]. A conservative strategy involves initial treatment with aggressive pharmacologic treatment, and coronary angiography with revascularization is used if there is evidence of spontaneous or provoked ischemia within the hospital stay. Two hundred sixty-one patients coronary syndrome were enrolled in this study for early invasive strategy. Patients received aspirin, heparin, clopidogrel, and lipid-lowering therapy. The primary endpoint was a composite of death, non-fatal myocardial infarction, cerebrivascular accident, and recurrent chest pain. Angiograms were assessed qualitatively by two expert invasive cardiologists. Sixty-seven percent of the patients underwent percutaneous [33%] or surgical [34%] revascularization. The overall death rate was 1.1%. In-hospital major adverse cardiac event [MACE] rate was 3.2% in the revascularization groups. According to the favorable in-hospital course in patients referred for PCI or CABG, it seems that accurate selection of patients who may be candidates for early invasive strategies is of paramount importance. We found that diabetes, cardiac enzyme elevations [Troponin T], ST/T changes, and the presence of two or more risk factors besides diabetes are powerful predictors of the patients who will undergo revascularization. Proper selection of patients admitted with ACS for invasive strategy is warranted. Positive cardiac enzymes [Troponin T], diabetes mellitus, and presence of two or more major CAD risk factors are helpful for patient selection

role of human platelet antigen 1 polymorphism in development of coronary artery stenosis in Iranian population

Aggregation is the final step in activation of platelets and is mediated by presentation of GPIIb/IIIa receptors on the platelet membrane that bands to fibrinogen and von Willebrand's factor. There are common mutations in GPIII structure that can change the behavior of the molecule and may change the pattern of interaction between platelets and injured endothelium, thus they can have prognostic impact in coronary artery disease [CAD] and acute coronary syndrome. In some large trials, persons homozygous for the PIA2 allele had a greater chance of coronary stenosis and myocardial infarction [MI] than heterozygotes or non-carriers, but other studies did not confirm this association. This is the first study of PIA polymorphism in Iran and is aimed to find a possible association of this mutation and CAD in the Iranian population. In this case-control study, we chose 200 patients who underwent diagnostic coronary angiography between 2005 and 2006 in Hamedan, Iran. In these patients HPIa genotype determination was done using PCR method. We found no significant association of coronary artery stenosis and PIA2A2 or P1A1A2 genotypes in our patients, p value > 0.05. However, there was a significant association between possession of P1A2 allele and occurrence of CAD in patients more than 50 years of age, p value 0.045. Variations in P1A phenotype do not seem to have an association with ischemic heart disease, but the P1A2 allele may have a role in the development of atherosclerosis and MI in persons more than 50 years of age

Detection of atherosclerotic plaque composition using intravascular images

Acute coronary syndromes [ACS] and sudden cardiac death are the main causes of morbidity and mortality in the world. ACS are often the first manifestation of coronary artery disease, and the rupture of a coronary plaque is the main cause of ACS. Histopathological studies have revealed that the majority of thrombi result from plaque rupture. Grayscale intravascular ultrasonography [IVUS], a tomographic imaging tool, can visualize coronary atherosclerosis in vivo, elucidating plaque area, plaque distribution, lesion length, and coronary remodeling. IVUS has demonstrated the discrepancies between the extent of atherosclerosis seen by coronary angiography and the actual extent of atherosclerotic disease. Quantitative assessment of plaque composition has, however, not been possible with grayscale IVUS analysis, until now

Health state valuation in Iran: an exercise on cardiovascular diseases using visual analogue scale method

Disability Weights [DWs] are main components for computing summary measure of population health [SMPH] and economic studies. They are specific for each community, but there are no previous studies in Iran. In this study, we investigated the feasibility of health state valuation [HSV] in Iranian population. Twelve cardiologists in 3 sessions of expert panels, defined 25 states, related to cardiovascular diseases [3 major and 22 specific diseases]. From January to March 2008, 80 persons in 4 groups including: physicians, patients, patients' families and general publics [each group 20], were interviewed and valuated the states, using visual analogue scale [VAS] method. SPSS[Registered] 15 for window[Registered] [SPSS Corporation, Chicago, Illinois] was used for statistical analysis. Data showed that the defined health states had various severities. All the 4 groups ranked the "3 major-diseases" and "very-mild" and "very-severe" states, similarly. Non-physicians were not able to differentiate among "valvular-diseases" and "pacemakers" properly. The reliability of responses was acceptable. VAS is an appropriate and reliable method for HSV in Iranian population. Non-physicians' opinions can be consider in major cardiac diseases. Valuation of more specific situations must perform by physicians