[Primary angioplasty in acute inferior myocardial infarct with anterior ST-segment depression: the long-term follow-up]. / Angioplastica primaria nell'infarto miocardico acuto inferiore con sottoslivellamento anteriore del tratto ST: follow-up a lungo termine.

BACKGROUND: Concomitant anterior ST-segment depression is a marker of severe prognosis in inferior myocardial infarction. PATIENTS AND METHODS: Prospective observational study in patients with inferior acute myocardial infarction and ST-segment depression > or = 4 mm in the anterior leads, who were treated with primary angioplasty. Angiography was performed at hospital discharge and at six months, and a clinical follow-up was obtained at one year after the infarction. RESULTS: Sixty-three patients were included in the study. Pre-hospital and in-hospital delay were 147 +/- 70 minutes (20-355) and 54 +/- 11 minutes (18-80), respectively. Angioplasty was successful in all patients and 48 stents were implanted in 36 patients (57%). Angiography was performed at hospital discharge in 55 patients (87%) and showed a TIMI grade 3 coronary flow in the infarct-related artery in all cases. The left ventricular ejection fraction was 0.55 +/- 0.09 (0.4-0.8). One patient (1.6%) died before discharge, two (3.2%) had ischemic complications (one had non-fatal reinfarction, another had recurrent angina at rest), and three (4.9%) had local vascular complications. At the six-month follow-up, none of the patients had died. One had suffered reinfarction (1.6%) and another had been readmitted for recurrence of angina at rest (1.6%); none had symptoms of stable angina. The ejection fraction was 0.56 +/- 0.12 and eight patients (14%) showed angiographic restenosis. At twelve months, two patients had died (1.6%) and five (8%) had required readmission to hospital. CONCLUSIONS: Primary angioplasty yielded favorable results in this group of patients. Our data confirm the efficacy of primary angioplasty for the treatment of acute myocardial infarction, with a low rate of clinical (3.2%) and angiographic (14%) restenosis at six months, and a high rate (87%) of event-free survival at one year follow-up.

Early aggressive treatment of unstable angina without on-site cardiac surgical facilities: a prospective study of acute and long-term outcome.

BACKGROUND: The early invasive diagnostic approach with extensive use of myocardial revascularization in patients with unstable angina is a matter of debate. Both the advantages of this strategy and the choice of the best candidates are controversial. The widespread applicability of this approach in Italian hospitals is also questionable, due to limited availability of facilities for interventional cardiology. METHODS: A prospective, observational study was done on a cohort of consecutive patients, who were admitted with a diagnosis of unstable angina and treated with an early aggressive approach at a center with interventional cardiology facilities without cardiac surgery. The aim of the study was to evaluate both the immediate and long-term clinical outcome of patients and the efficiency of our therapeutic approach. RESULTS: Two-hundred and two patients were enrolled and 85% were in Braunwald class III. Coronary angiography was performed in 171 patients (85%) at 2.1 +/- 2.4 days after admission: it showed one-, two- and three-vessel disease in 40, 29 and 22% of cases, respectively; 9% of patients had no severe coronary lesion. Left ventricular ejection fraction was 0.58 +/- 0.13. Medical treatment, coronary by-pass surgery and percutaneous myocardial revascularization were chosen in 36, 24 and 40% of cases, respectively. Coronary angioplasty was performed in our center in 58 (73%) of 80 patients at 6.8 +/- 5.6 days after admission and stents were used in 42 cases (74%). Overall hospital stay was 10.4 +/- 4 days. Cumulated adverse events (death and non-fatal myocardial infarction) occurred in 2.5 and 7% of patients during the initial admission and in the following year, respectively. CONCLUSIONS: An early aggressive approach to patients with unstable angina is feasible in a hospital with interventional cardiology in the absence of cardiac surgical facilities. The immediate favorable clinical results of this strategy in an intermediate-risk cohort seem to persist at one-year follow-up.

[The use of a check list for quality assurance of the treatment of acute myocardial infarction in the coronary care unit]. / Uso di un registro per il controllo di qualità del trattamento dell'infarto miocardico acuto in unità coronarica.

UNLABELLED: The implementation of Quality Assurance programs for the treatment of acute myocardial infarction in the Cardiac Intensive Care Unit may be specially important. In fact several therapeutic options are available in these patients, and delay in treatment must be as short as possible. A Quality Assurance program has been started in our center with a registry of all patients admitted within 24 hours of onset of acute myocardial infarction. PATIENTS AND METHODS: The following data were recorded: 1) indicators of Organization: pathway to admission, pre-hospital and in-hospital delay; 2) Process Indicators: duration of hospital stay, initial choice of therapy (conservative, intravenous lysis, primary angioplasty), and further diagnostic and interventional procedures; 3) Outcome Indicators: mortality and complications during admission, and 6-12 months follow-up. RESULTS: Since february 1994 to August 1995, 211 consecutive patients were included in the registry; 156 were male, mean age 66 years. Mean pre-hospital delay was 286 minutes. Admission was decided by a physician in 99 cases and by the patient him/herself in 112 cases; pre-hospital delay was 390 min. In the former group, and 194 min. In the latter (p < .001). Mean in-hospital delay was 61 minutes. Conservative treatment, intravenous lysis, and primary angioplasty were chosen by the attending cardiologist in 89 patients (group A), 69 patients (group B), and 53 patients (group C) respectively. The latter group included patients with highest risk on the basis of clinical and electrocardiographic characteristics. In-hospital mortality was 17, 7 and 9% In the 3 groups, respectively. An echocardiogram and coronary angiography were performed before discharge in 81% and 57% of patients, respectively. The mean duration of hospital stay was 11 days, irrespective of the initial therapeutic choice. CONCLUSIONS: A registry for patients with acute myocardial infarction provides information which is essential in the evaluation of therapeutic protocols; it may also help in improving the cooperation between the Emergency Department, the attending cardiologists, and the family physicians.

Physician perception of exercise electrocardiography as a prognostic test after acute myocardial infarction.

To determine how physicians interpret exercise electrocardiography with respect to prognosis after acute myocardial infarction (AMI), 29 cardiologists (all board certified) were presented a case history of a 50-year-old man with an uncomplicated AMI and asked to estimate the patient's risk of dying over the next year, the sensitivity and specificity of exercise electrocardiography with respect to 1-year mortality, and the patient's risk of dying given a positive and a negative test result. Each set of physician estimates did not differ from those derived from a review of the medical literature (difference not significant for each). Risk after the test was also calculated using the Bayes' theorem. Calculated versus estimated risks were compared after a negative (7 +/- 9 vs 11 +/- 11%) and a positive (27 +/- 22 vs 17 +/- 15%, differences not significant) test result. Estimated risks were more accurate for a negative result than for a positive one (89 +/- 10 vs 83 +/- 12%, p less than 0.001). Given a positive test result, 57% of the physicians recommended coronary angiography. However, their estimates of risk (30 +/- 23%) were not significantly different from the estimates of those physicians (14%) who recommended additional noninvasive testing (19 +/- 4%) or those (29%) who recommended medical therapy (28 +/- 26%) (difference not significant). Thus, cardiologists accurately estimated prognosis following AMI, but they were less accurate in assessing high risk than low risk, and their management decisions correlated poorly with their risk assessments.