Non-invasive imaging techniques and assessment of carotid vasa vasorum neovascularization: Promises and pitfalls.

Carotid adventitia vasa vasorum neovascularization (VVn) is associated with the initial stages of arteriosclerosis and with the formation of unstable plaque. However, techniques to accurately quantify that neovascularization in a standard, fast, non-invasive, and efficient way are still lacking. The development of such techniques holds the promise of enabling wide, inexpensive, and safe screening programs that could stratify patients and help in personalized preventive cardiovascular medicine. In this paper, we review the recent scientific literature pertaining to imaging techniques that could set the stage for the development of standard methods for quantitative assessment of atherosclerotic plaque and carotid VVn. We present and discuss the alternative imaging techniques being used in clinical practice and we review the computational developments that are contributing to speed up image analysis and interpretation. We conclude that one of the greatest upcoming challenges will be the use of machine learning techniques to develop automated methods that assist in the interpretation of images to stratify patients according to their risk.

Utilidad de las técnicas de imagen y biomarcadores en la predicción del riesgo cardiovascular en pacientes con enfermedad renal crónica en España: Proyecto NEFRONA* / Usefulness of imaging techniques and novel biomarkers in the prediction of cardiovascular risk in patients with chronic kidney disease in Spain: The NEFRONA project

Justificación: La enfermedad cardiovascular (ECV) es la primera causa de mortalidad en pacientes con enfermedad renal crónica (ERC). La valoración del riesgo cardiovascular a partir de los factores tradicionales es poco útil en esta población debido al fenómeno de «reverse epidemiology» y a la existencia de factores específicos derivados de la uremia. En este trabajo presentamos el protocolo del proyecto NEFRONA, un estudio prospectivo con el objetivo de evaluar la utilidad de técnicas de imagen y biomarcadores en la predicción de la ECV en la ERC. Métodos: A partir de noviembre 2009 se reclutarán 2.661adultos asintomáticos con ERC (estadios 3-5D) procedentes de consultas ambulatorias de nefrología y centros de diálisis distribuidos a lo largo del territorio español. Asimismo, se incluirán843 participantes sin ERC (grupo control). Además, semestralmente se registrará la aparición de acontecimientos cardiovasculares y mortalidad. Un equipo itinerante realizará una ecografía carotíde a para valorar el grosor íntima-media y la presencia de placas, y determinará el índice tobillo-brazo para la clasificación de la enfermedad ateromatosa. Para el estudio de las calcificaciones vasculares se utilizará un score basado en la presencia de calcificaciones en las arterias carótidas, femorales y braquiales, y en las válvulas cardíacas, mediante ecografía. Finalmente, se recogerán muestras de sangre para la determinación de biomarcadores. Discusión: El proyecto NEFRONA nos permitirá evaluar la utilidad de las técnicas de imagen y biomarcadores en la valoración de la enfermedad ateromatosa y su valor predictivo en la población española con ERC (AU)

Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with chronic kidney disease(CKD). Cardiovascular risk assessment in this population is hampered by the failure of traditional risk factors to fully account for the elevated CVD risk, mainly due to the reverse epidemiology effect, and the presence of risk factors specifically related to uremia. Hereby, we present the protocol of a prospective study aimed to assess the predictive value of imaging techniques and biomarkers for CVD in patients with CKD. Methods: From November 2009, 2.661asymptomatic adult patients with stages 3-5D CKD will be recruited from nephrology services and dialysis units throughout Spain. Eighthundred forty-three participants without CKD (control group) will be also recruited. During the follow-up, CVD events and mortality will be recorded from all CKD patients. One trained itinerant team will carry out a carotid ultrasound to assess intima-media thickness and presence of plaques. A composite atherosclerosis score will be constructed based on carotid ultrasound data and ankle-brachialindex. Presence and type of calcifications will be assessed in carotid, femoral and brachial arteries, and in cardiac valves, by ultrasound. Finally, blood samples will be collected from all participants to study biomarkers. Discussion: The NEFRONA study will allow us to examine the usefulness of imaging techniques and biomarkers to assess atherosclerosis development and their predictive value in a Spanish population with CKD (AU)

Estudio prospectivo multicéntrico de calidad en hemodiálisis / Hemodialysis prospectiva multicentric quality study

En el ámbito médico se destinan muchos recursos a la investigación. Sin embargo, los esfuerzos encaminados a evaluar la eficacia de estrategias útiles para trasladar la evidencia científica disponible a la práctica clínica son relativamente escasos. El presente trabajo pretende estudiar la eficacia de ciertas medidas de gestión clínica (feedback, benchmarking y Planes de Mejora) en el resultado del tratamiento con hemodiálisis mediante un estudio prospectivo realizado en 4 centros de diálisis. Se procedió a la monitorización periódica (cada 6-8 meses) de indicadores de hemodiálisis previamente consensuados, informando de los resultados propios de cada centro (feedback) y de éstos en relación al resto (benchmarking). Se elaboraron Planes de Mejora específicos en función de los resultados. Tras dos años de seguimiento el número total de pacientes incluidos ha sido de 294. Se ha obtenido una mejora estadísticamente significativa de los indicadores: % de pacientes con Hb 5 mg/dl. No ha habido cambios estadísticamente significativos en los indicadores: dosis media de eritropoyetina (EPO), tensión arterial (TA), fósforo plasmático (P), Ca x P, parathormona (PTHi) y distribución de accesos vasculares. Las causas que explican la ausencia de modificación de éstos últimos son diversas: situación de partida adecuada de algunos indicadores (TA y accesos), recursos terapéuticos de limitada eficacia (vitamina D, quelantes y otros), recursos de apoyo insuficientes (unidades de dietética), o la elaboración/implantación incorrecta de Planes de Mejora. En conclusión, los instrumentos de gestión clínica implantados, son eficaces para la mejora de los resultados asistenciales de ciertos aspectos de la hemodiálisis (anemia, dosis de diálisis, nutrición e inflamación), aunque han resultado de nula eficacia para mejorar los resultados del metabolismo calcio-fósforo

In medicine a considerable amount of resources are used in research, but very little attention is paid to ensuring that the findings of research are implemented in routine clinical practice. This prospective study has the aim to evaluate the efficiency of some clinical management strategies (feedback, benchmarking and improving plans) on haemodialysis treatment results in 4 different dialysis centres We collected consensus data related to haemodialysis results every 6-8 months and informed each centre about its own results (feedback) and how these related to the others (benchmarking). We designed improving plans for any bad result detected. By the end of two years of follow up, 294 patients had been included in the study. The results obtained at the end of the study had improved in comparison with those obtained at the beginning (statistically significant) for the following indicators: % of patients with Hb 5 mg/dl. No statistical changes were found in: mean erythropoietin (EPO) doses, blood pressure (BP), phosphorus plasmatic, calcium-phosphorus product, parathormone (PTHi) and vascular access distribution. We explained the absence of any improvement because of adequate start indicators in some areas (BP and vascular access), therapy with limited efficiency (calcitriol, calcium carbonate and others), lack of support resources (dietetic unit) or inadequate design/implementation of improving plans. In conclusion, our intervention illustrates that combined clinical management strategies (feedback, benchmarking and improving plans) are efficiency in improving some areas of haemodialysis treatment (anaemia, dialysis dose, nutrition and inflammation), although it does not improve calcium phosphate metabolism related indicators

[Hemodialysis prospective multicentric quality study]. / Estudio prospectivo multicentrico de calidad en hemodialisis.

In medicine a considerable amount of resources are used in research, but very little attention is paid to ensuring that the findings of research are implemented in routine clinical practice. This prospective study has the aim to evaluate the efficiency of some clinical management strategies (feedback, benchmarking and improving plans) on haemodialysis treatment results in 4 different dialysis centres. We collected consensus data related to haemodialysis results every 6-8 months and informed each centre about its own results (feedback) and how these related to the others(benchmarking). We designed improving plans for any bad result detected. By the end of two years of follow up, 294 patients had been included in the study. The results obtained at the end of the study had improved in comparison with those obtained at the beginning (statistically significant) for the following indicators: % of patients with Hb< 11 g/dl, % patients with Kt/v < 1.2, mean Kt/v, mean albumin, % patients with albumin< 3.5 g/dl y % patients with C reactive protein (CRP) > 5 mg/dl. No statistical changes were found in: mean erythropoietin (EPO) doses, blood pressure (BP), phosphorus plasmatic,calcium-phosphorus product, parathormone (PTHi) and vascular access distribution. We explained the absence of any improvement because of adequate start indicators in some areas (BP and vascular access), therapy with limited efficiency (calcitriol, calcium carbonate and others), lack of support resources (dietetic unit) or inadequate design/implementation of improving plans.In conclusion, our intervention illustrates that combined clinical management strategies(feedback, benchmarking and improving plans) are efficiency in improving some areas of haemodialysis treatment (anaemia, dialysis dose, nutrition and inflammation), although it does not improve calcium phosphate metabolism related indicators.

Recommendations on percutaneous coronary intervention for the reperfusion of acute ST elevation myocardial infarction.

Little information is currently available from the various societies of cardiology on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Since primary PCI is the main method of reperfusion in AMI in many centres, and since of all cardiac emergencies AMI represents the most urgent situation for PCI, recommendations based on scientific evidence and expert experience would be useful for centres practising primary PCI, or those looking to establish a primary PCI programme. To this aim, a task force for primary PCI in AMI was formed to develop a set of recommendations to complement and assist clinical judgment. This paper represents the product of their recommendations.

Collaborative Angiographic Patency Trial Of Recombinant Staphylokinase (CAPTORS II).

AIMS: A fibrinolytic agent more effective than streptokinase available for bolus injection with reasonable cost-effectiveness is a desirable goal. Pilot studies with bolus pegulated staphylokinase (PEG-Sak) have revealed excellent Thrombolysis In Myocardial Infarction (TIMI) 3 60-minute flow. METHODS AND RESULTS: We evaluated patients with acute ST-elevation myocardial infarction within 6 hours of chest pain onset to determine a dose of PEG-Sak that had at least equal efficacy to recombinant tissue plasminogen activator (rt-PA) while maintaining an acceptable safety profile. After the initial study of 38 patients, of whom 27 received PEG-Sak, enrollment was temporarily halted because 3 patients receiving PEG-Sak had intracranial hemorrhage: 1 at a dose of 0.15 mg/kg and 2 at a dose of 0.05 mg/kg. Overall, 378 patients were studied across a PEG-Sak dose range from 0.01 mg/kg to 0.015 mg/kg, and 122 patients received accelerated rt-PA. At the lowest dose of PEG-Sak studied, 0.01 mg/kg, there was suggestive evidence of attenuation of efficacy; the point estimate for TIMI 3 flow was 24% (95% CI 9%-38%). At doses of 0.01875 to 0.0375 mg/kg (n = 314), TIMI 3 flow rates were 33% (95% CI 27%-38%), whereas the TIMI 3 flow was 41% (95% CI 20%-61%) at the highest PEG-Sak dose studied, 0.05 mg/kg (n = 23), which was similar to that found with rt-PA, 41% (95% CI 32%-50%). CONCLUSION: The efficacy of PEG-Sak, coupled with its ease of administration, provide further impetus for further study in acute myocardial infarction.

Incidence and predictors of bleeding events after fibrinolytic therapy with fibrin-specific agents: a comparison of TNK-tPA and rt-PA.

BACKGROUND: Fibrinolytic therapy increases the risk of bleeding events. TNK-tPA (tenecteplase) is a variant of rt-PA with greater fibrin specificity and reduced plasma clearance that can be given as a single bolus. We compared the incidence and predictors of bleeding events after treatment with TNK-tPA and rt-PA. METHODS AND RESULTS: In the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT)-2 trial, 16 949 patients with acute myocardial infarction were randomly assigned a single weight-adjusted bolus of TNK-tPA or a 90-min infusion of rt-PA. A total of 4.66% of patients in the TNK-tPA group experienced major non-cerebral bleeding, in comparison with 5.94% in the rt-PA group (P=0.0002). This lower rate was associated with a significant reduction in the need for blood transfusion (4.25% vs 5.49%, P=0.0003) and was consistent across subgroups. Independent risk factors for major bleeding were older age, female gender, lower body weight, enrolment in the U.S.A. and a diastolic blood pressure <70 mmHg. Females at high risk (age >75 years and body weight <67 kg) were less likely to have major bleeding when treated with TNK-tPA even after other risk factors were taken into account. A total of 0.93% of patients in the TNK-tPA and 0.94% of patients in the rt-PA group experienced an intracranial haemorrhage. Female patients >75 years of age who weighed <67 kg tended to have lower rates of intracranial haemorrhage when treated with TNK-tPA (3/264, 1.14% vs 8/265, 3.02%). CONCLUSIONS: The increased fibrin specificity and single bolus administration of TNK-tPA do not increase the risk of intracranial haemorrhage but are associated with less non-cerebral bleeding, especially amongst high-risk patients.

Influence of vitamin D receptor gene polymorphisms on mortality risk in hemodialysis patients.

The BsmI polymorphism of the vitamin D receptor (VDR) gene influences mineral metabolism and the course of cancers and infections. The poly-A polymorphism is in linkage disequilibrium with BsmI and could be responsible for clinical associations attributed to BsmI. The objective of this work is to study the influence of VDR polymorphisms on survival of 143 prevalent hemodialysis (HD) patients followed up for 4 years. Chi-square test was used to study the association between survival and these polymorphisms. Cox analysis was performed, adjusting for comorbid conditions in the entire HD population, groups of patients on HD therapy for less than 5 and 3 years before entering 4 years of observation, patients without diabetes, and patients treated with calcitriol. Survival was analyzed by means of Kaplan-Meier according to BsmI genotypes. Results showed a strong influence of the BsmI polymorphism on survival. The bb genotype was overrepresented among survivors (45.7%) compared with nonsurvivors (21.6%), and Cox analysis showed a significant influence of age, diabetes, calcitriol treatment, and BsmI polymorphism in all groups (in the entire population, Exp(B): BB, 3.9; and Bb, 3 with respect to bb), and also of phosphorus in patients without diabetes and calcitriol-treated patients. Survival means by Kaplan-Meier were as follows: BB, 983 days; Bb, 1,152 days; and bb, 1,290 days (log-rank P = 0.01). The BsmI polymorphism influences survival in HD patients, whereas the poly-A and FokI polymorphisms do not.

Influence of Bsml vitamin D receptor gene polymorphism on the response to a single bolus of calcitrol in hemodialysis patients.

AIMS: BsmI polymorphism of the vitamin D receptor gene has been linked to hyperparathyroidism severity and calcitriol levels. The aim of this study was to analyze the response to a single bolus of calcitriol in hemodialysis patients with the BB and bb genotype. PATIENTS: Twenty homozygous BsmI hemodialysis patients (9 BB and 11 bb). METHODS: Hyperparathyroidism was assessed comparing basal PTH levels, and in 17 patients, also measuring the inhibition with hypercalcemia. Patients were given a bolus of calcitriol and PTH in absolute terms and in percentages relative to the baseline values at 24, 48 and 72 hours after the bolus were measured. All biochemical parameters were compared between genotypes with univariant ANOVA and additionally, PTH relative values were compared with general factorial analysis of variance, adjusting for calcium and phosphorus. Means were also compared within each genotype between consecutive determinations with non-parametric Wilcoxon analysis, using each patient as his/her own control. The response to calcitriol was also assessed by the area under the curve for each patient and was subsequently compared between genotypes. RESULTS: There were no differences on hyperparathyroidism severity between the groups. The BB genotype showed a better response than bb to calcitriol 72 hours after the bolus (percentage relative to basal PTH value: BB: 63%, bb: 88.6%, p = 0.03; BB vs bb with univariant ANOVA). When general factorial analysis of variance was applied, adjusting for serum calcium and phosphorus, genotype showed a significant influence on the response to calcitriol at 72 hours (p = 0.04). When each patient was used as his/her own control, the BB genotype showed a significant decrease in PTH levels at 48 and 72 hours (p = 0.00 baseline vs 48 h, and p = 0.01 baseline vs 72h) whereas the bb did not. CONCLUSIONS: BsmI polymorphism of the VDR gene induces differences on the response to a single bolus of calcitriol independently of calcium and phosphorus.

Reactivation of ischemic events in acute coronary syndromes: results from GUSTO-IIb. Gobal Use of Strategies To Open occluded arteries in acute coronary syndromes.

OBJECTIVES: We sought to determine the incidence of and risk factors for thrombotic events early after discontinuing antithrombin therapy in patients with acute coronary syndromes. BACKGROUND: Discontinuation of treatment with heparin and other thrombin inhibitors in patients with unstable coronary syndromes has related to clinical and biochemical evidence of early reactivation of thrombosis. METHODS: We studied 8,943 of the 12,142 patients with acute coronary syndromes enrolled in the Global Use of Strategies To Open occluded arteries in acute coronary syndromes trial of hirudin versus heparin. We excluded patients who received no study drug, lacked timing data, died or had myocardial (re)infarction [(re)MI] during study-drug infusion, or began heparin treatment within 2 h after treatment with the study drug was stopped. We assessed the incidence and timing of (re)MI by type and timing of antithrombin treatment. RESULTS: In all, 215 patients (2.4%) suffered (re)MI, 49 within 12 h of antithrombin therapy discontinuation and 166 between hour 12 and hospital discharge. The duration of infusion did not differ between the hirudin and heparin groups. The rate of early re(MI) after drug therapy discontinuation was significantly higher in patients given heparin versus hirudin (0.8% vs. 0.3%, p = 0.002). Patients with (re)MI had higher mortality at 30 days (23.6% vs. 2.4%, p = 0.001) and 1 year (35.2% vs. 6.7%, p = 0.001) compared with patients without (re)MI. CONCLUSIONS: The incidence of (re)MI was clustered within 12 h of heparin therapy discontinuation, with the greatest risk within 4 h. There was no evidence of early reactivation of thrombotic events after hirudin. Patients who had (re)infarction had worse outcomes. Better understanding of the mechanism and possible prevention of recurrent thrombosis is needed.

Coronary artery revascularization in patients with sustained ventricular arrhythmias in the chronic phase of a myocardial infarction: effects on the electrophysiologic substrate and outcome.

OBJECTIVES: The objective of this study was to analyze the influence of coronary artery revascularization in patients with ventricular arrhythmias. BACKGROUND: Coronary artery revascularization is an effective treatment for myocardial ischemia; however, its effect on ventricular arrhythmias not related to an acute ischemic event has not been carefully studied. METHODS: Sixty-four patients (58 men, mean age 65 +/- 8 years old) with prior myocardial infarction, spontaneous ventricular arrhythmias not related to an acute ischemic event (55 ventricular tachycardia, 9 ventricular fibrillation) and coronary lesions requiring revascularization were studied prospectively. Electrophysiological study was performed before and after revascularization, and events during follow-up were analyzed. RESULTS: At initial study 61 patients were inducible into sustained ventricular arrhythmias. After revascularization, in 62 survivors, 52 out of 59 patients previously inducible were still inducible (group A), and 10 patients were noninducible (group B). No differences were found in clinical, hemodynamic, therapeutic and electrophysiological characteristics between both groups. During 32 +/- 26 months follow-up, 28/52 patients in group A (54%) and 4/10 patients in group B (40%) had arrhythmic events (p = 0.46). An ejection fraction <30% predicted recurrent arrhythmic events (p = 0.02), but not the presence of demonstrable ischemia before revascularization (p = 0.42), amiodarone (p = 0.69) or beta-adrenergic blocking agent therapy (p = 0.53). Total mortality was 10% in both groups. CONCLUSIONS: In patients with ventricular arrhythmias in the chronic phase of myocardial infarction, probability of recurrence is high despite coronary artery revascularization, but mortality is low if combined with appropriate antiarrhythmic therapy. Recurrences are related to the presence of a low ejection fraction but not to demonstrable ischemia before revascularization, amiodarone or beta-blocker therapy nor are they the results of electrophysiological testing after revascularization.

Facilitation of early percutaneous coronary intervention after reteplase with or without abciximab in acute myocardial infarction: results from the SPEED (GUSTO-4 Pilot) Trial.

OBJECTIVES: We examined the utility of early percutaneous coronary intervention (PCI) in a trial that encouraged its use after thrombolysis and glycoprotein IIb/IIIa inhibition for acute myocardial infarction (MI). BACKGROUND: Early PCI has shown no benefit when performed early after thrombolysis alone. METHODS: We studied 323 patients (61%) who underwent PCI with planned initial angiography, at a median 63 min after reperfusion therapy began. A blinded core laboratory reviewed cineangiograms. Ischemic events, bleeding, angiographic results, and clinical outcomes were compared between early PCI and no-PCI patients (n = 162), between patients with Thrombolysis in Myocardial Infarction (TIMI) flow grade 0 or 1 before PCI versus flow grade 2 or 3, and among three treatment regimens. RESULTS: Early PCI patients showed a procedural success (<50% residual stenosis and TIMI flow grade 3) rate of 88% and a 30-day composite incidence of death, reinfarction, or urgent revascularization of 5.6%. These patients had fewer ischemic events and bleeding complications (15%) than did patients not undergoing early PCI (30%, p = 0.001). Early PCI was used more often in patients with initial TIMI flow grade 0 or 1 versus flow grade 2 or 3 (83% vs. 60%, p < 0.0001). Patients receiving abciximab with reduced-dose reteplase (5 U double bolus) showed an 86% incidence of TIMI grade 3 flow at approximately 90 min and a trend toward improved outcomes. CONCLUSIONS: In this analysis, early PCI facilitated by a combination of abciximab and reduced-dose reteplase was safe and effective. This approach has several advantages for acute MI patients, which should be confirmed in a dedicated, randomized trial.

Survival outcomes 1 year after reperfusion therapy with either alteplase or reteplase for acute myocardial infarction: results from the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) III Trial.

BACKGROUND: New recombinant plasminogen activators have been developed to simulate the fibrinolytic action of the physiological serine protease tissue plasminogen activator (alteplase, t-PA), and have prolonged half-life features permitting bolus administration. One such activator, reteplase (r-PA), was compared with t-PA in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-III Trial. METHODS AND RESULTS: At 1-year follow-up, survival status was ascertained in 97.4% of the 15 059 patients enrolled in the GUSTO-III trial. At 1 year, the mortality rate for the t-PA-assigned group was 11.06%, and for r-PA it was 11.20% (P:=0. 77). The absolute mortality difference of 0.14% has 95% CIs of -1. 21% to 0.93%. There were no significant differences in outcome by intention-to-treat for the 2 different plasminogen activators in the prespecified groups (age, infarct location, time-to-treatment). The absolute difference in mortality rates between t-PA and r-PA progressively narrowed over the predetermined observation times after random assignment; it was 0.31% at 24 hours, 0.26% at 7 days, 0.23% at 30 days, and 0.14% at 1 year. Of note, mortality rate in the trial between 30 days and 1 year in 13 883 patients was 4.02% and did not differ between the treatment groups. However, this mortality rate was substantially greater than in GUSTO-I, in which mortality rate for t-PA versus streptokinase between 30 days and 1-year was 2.97% (heart rate 1.36, 95% CI 1.23, 1.50, P:<0.001). CONCLUSIONS: The r-PA and t-PA strategies yielded similar survival outcomes after 30 days in this trial. The increase in mortality rate during extended follow-up compared with previous trials may reflect higher-risk patients and highlights the need for improved secondary prevention strategies.

Carvedilol for prevention of restenosis after directional coronary atherectomy : final results of the European carvedilol atherectomy restenosis (EUROCARE) trial.

BACKGROUND: In addition to its known properties as a competitive, nonselective beta and alpha-1 receptor blocker, carvedilol directly inhibits vascular myocyte migration and proliferation and exerts antioxidant effects that are considerably greater than those of vitamin E or probucol. This provides the basis for an evaluation of carvedilol for the prevention of coronary restenosis. METHODS AND RESULTS: In a prospective, double-blind, randomized, placebo-controlled trial, 25 mg of carvedilol was given twice daily, starting 24 hours before scheduled directional coronary atherectomy and continuing for 5 months after a successful procedure. The primary end point was the minimal luminal diameter as determined during follow-up angiography 26+/-2 weeks after the procedure. Of 406 randomized patients, 377 underwent attempted atherectomy, and in 324 (88.9%), a

Predictors of death and reinfarction at 30 days after primary angioplasty: the GUSTO IIb and RAPPORT trials.

BACKGROUND: Thirty-day death among recipients of fibrinolytic therapy for acute myocardial infarction (MI) is tightly correlated with easily obtainable key demographic and clinical parameters such as age, blood pressure, heart rate, and infarct location. Similar data for primary angioplasty are not available. METHODS AND RESULTS: Data from 2 large, contemporary, primary angioplasty trials were formally combined and analyzed with respect to death and death/repeat MI at 30 days through the use of multivariate logistic regression models. The 1048 patients had a median age of 62 years, and 26% were women. Thirty-eight percent had an anterior infarction. The patients underwent angioplasty at a median delay from symptom onset of 3.8 hours. Death was independently predicted by increasing age (adjusted odds ratio [OR] per decade 2.32, 95% confidence interval [CI] 1.60 to 3.42), whereas a history of smoking (OR 0.29, CI 0.13 to 0.64), Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 after angioplasty (OR vs TIMI <3 0.21, CI 0.10 to 0.45) and higher systolic blood pressure (OR per 10 mm Hg 0.73, CI 0.62 to 0. 87) were associated with lower mortality rates. Death or repeat MI was independently associated with increasing age (OR per decade 1.40, CI 1.13 to 1.76) and anterior location of the index MI (OR 1.89, CI 1.12 to 3.20). TIMI grade 3 flow (OR vs TIMI <3 0.40, CI 0.23 to 0. 68) and higher systolic blood pressure (OR per 10 mm Hg 0.79, CI 0. 71 to 0.89) were associated with a lower incidence of death/repeat MI. Time to angioplasty, heart rate, extent of coronary artery disease, participation in 1 of the 2 trials, and all common coronary risk factors did not significantly predict outcome. CONCLUSIONS: Death and reinfarction after primary angioplasty are predominantly predicted by age, hemodynamic instability, and the attainment of TIMI 3 flow in the infarct artery.

[In-hospital evolution and current prognosis of unstable angina]. / Evolución hospitalaria y pronóstico actual de la angina inestable.

INTRODUCTION AND PROGNOSIS: The prognosis of patients with unstable angina has improved in recent years resulting in a progressive reduction in hospital stay and treatment. The aim of this study was to know the current prognosis of patients with unstable angina in a non-selected population followed for up to 3 months. PATIENTS AND METHODS: 478 consecutive patients with unstable angina were studied. They were treated following a strict protocol and a management policy guided by symptoms and the results of an exercise test or a pharmacological stress test performed before hospital discharge. RESULTS: The mean age was 66 +/- 11 years with 30% being females. Thirty-five percent had a prior history of myocardial infarction, 61% presented ischemic changes on the admission ECG, and 16% had elevation of the CK-MB plasma levels. An echocardiogram was performed in 80% of the patients, a stress test in 62%, coronary angiography in 51%, and a revascularization procedure in 27% of the patients. During hospitalization, the incidence of mortality or myocardial infarction, refractory angina or ischemic complications was of 3.6%, 11% and 13%, respectively. After hospital discharge and during a 3-month follow-up, the incidence of these complications was of 3.3%, 9% and 10% (NS compared to the in-hospital period). Overall, from the time of hospital admission to the 3-month follow-up, 4.2% of the patients died, 7% died or had an infarction, 20% had refractory angina, and 26% had some ischemic complication. CONCLUSION: The in-hospital prognosis of unstable angina is currently good. However, patients discharged from hospital after stabilization, present an important number of ischemic complications during the following 3 months, similar to that presented by all patients during the acute phase.

A comparison of ionic versus nonionic contrast medium during primary percutaneous transluminal coronary angioplasty for acute myocardial infarction (GUSTO IIb). Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes.

The clinical impact of contrast medium selection during primary percutaneous transluminal coronary angioplasty for acute myocardial infarction (AMI) has not been studied. We compared the clinical outcomes of patients who received ionic versus nonionic low osmolar contrast medium in the setting of primary percutaneous transluminal coronary angioplasty for AMI in the second Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) trial. Univariable and multivariable analyses were performed to assess the relation between contrast medium selection and clinical outcome (death, reinfarction, or refractory ischemia) at 30 days. Although baseline clinical and angiographic characteristics were generally similar between the 2 groups, patients who received ionic, low osmolar contrast were less likely to have been enrolled at a US site (23% vs 43%, p = 0.001) and less likely to have occlusion of the left anterior descending coronary artery (34% vs 47%, p = 0.03) or a history of prior AMI (8% vs 16%, p = 0.02). The triple composite end point of death, reinfarction, or refractory ischemia occurred less frequently in the ionic group, both in the hospital (4.4% vs 11%, p = 0.018) and at 30 days (5.5% vs 11%, p = 0.044). Although the trend favoring ionic contrast persisted, the differences were no longer statistically significant after adjustment for imbalances in baseline characteristics using a risk model developed from the study sample (n = 454, adjusted odds ratio for ionic contrast 0.48 [0.22 to 1.02], p = 0.055), and using a model developed from the entire GUSTO IIb study cohort (n = 12,142, adjusted odds ratio for ionic contrast 0.50 [0.23 to 1.06], p = 0.072). The results of this observational study warrant further elucidation by a randomized study design in this setting.