Return to work after acute ST-segment elevation myocardial infarction in the modern era of reperfusion by direct percutaneous coronary intervention.

BACKGROUND: Previous studies have evaluated return to work after acute ST-segment elevation myocardial infarction (STEMI) treated medically, after bypass surgery or after percutaneous coronary intervention (PCI) for stable coronary artery disease. However, there are few data regarding return to work after acute STEMI treated by direct PCI. AIMS: To analyse the factors influencing return to work after STEMI treated by direct PCI. METHODS: Two hundred consecutive patients who underwent direct PCI for acute STEMI and who were employed at the time of their STEMI were studied. Stents were used in 94% of patients and glycoprotein IIb/IIIa inhibitors in 77%. RESULTS: Among the 200 patients, 152 (76%) patients returned to work and 48 (24%) did not. Patients who did not return to work did not differ from those who returned to work in terms of time from onset of chest pain to PCI, STEMI location, left ventricular function, extent of vessel disease, PCI technique and success, completeness of revascularization, duration of hospital stay, intrahospital complications and performance of cardiac rehabilitation. Multivariable analysis showed that older age, daytime onset of chest pain, manual labour, rapid call-out of the emergency medical team, unmarried status and a limited number of risk factors were independent predictors of non-return to work. CONCLUSION: Age, sociopsychological and occupational factors appear to be the strongest predictors of return to work after STEMI treated by direct PCI. Clinical and procedural factors as well as cardiac rehabilitation appear to have no impact on return to work in this subset of patients.

A new approach of primary angioplasty for ST-elevation acute myocardial infarction based on minimalist immediate mechanical intervention.

OBJECTIVES: No reflow has been reported in 12-30% of the patients directly revascularized by angioplasty for acute ST elevation myocardial infarction with the highest incidence after primary stenting in patients with initial thrombolysis in myocardial infarction (TIMI) grade 0 flow. We hypothesized that a minimalist immediate mechanical intervention (MIMI) based on the use of very small size balloons to avoid both large dissection and distal embolization may be sufficient to restore flow in emergency and that recanalization may be sustained by maximized antithrombotic regimen (abcximab, clopidogrel, aspirin and heparin) allowing one to postpone stenting in better conditions. METHODS: MIMI was performed in 93 patients for ST elevation myocardial infarction with initial TIMI grade 0 flow. RESULTS: MIMI resulted in a TIMI grade 3 flow in 77/93 patients (83%). Immediate stenting was performed in the 16 patients with failed MIMI and resulted in a TIMI grade 3 flow in nine (56%). The residual stenosis after MIMI was 81+/-11% and ST segment resolution (> or =50%) at 1 h after reperfusion was obtained in 84%. Stenting was performed the following days in 52 patients with a post-stenting TIMI grade 3 flow in 50 (96%; 100% when stenting done beyond 24 h). No reocclusion occurred between MIMI and stenting. Among the 25 patients without stenting, six had mild stenosis at control angiogram and underwent medical treatment whereas 19 had multiple vessel disease and underwent bypass surgery. CONCLUSIONS: MIMI combined with maximized antithrombotic therapy results in immediate and sustained recanalization with a high rate of ST resolution in a majority of patients with ST elevation myocardial infarction. This approach allows one to postpone stenting in more stable conditions with a low rate of TIMI flow deterioration or to schedule more appropriate medical or surgical alternative management.

How important is the impact of pressure recovery on routine evaluation of aortic stenosis? A clinical study in 91 patients.

BACKGROUND AND AIM OF THE STUDY: Experimental investigations and invasive studies conducted in small series of patients using specially designed high-fidelity micromanometer tip catheters have suggested that downstream pressure recovery (PR) within the aorta may significantly affect transvalvular pressure gradient (PG) measurement. The study aims were to evaluate in a large cohort of patients the extent of PR when transvalvular PGs are routinely measured by fluid-filled pigtail side-hole catheters (FPC) using pullback from the left ventricle to the ascending aorta (AO), and to analyze factors influencing PR. The influence of PR on the correlation between catheter and Doppler PG measurements was also assessed in a subset of patients. METHODS: Transvalvular PG were measured in 91 patients with aortic stenosis using FPC pullback with the catheter positioned at different sites within the ascending aorta. In 71 patients, Doppler echocardiography was obtained within 24 h of catheterization. RESULTS: Mean PR ranged from 0 to 20 mmHg, corresponding to a PR index (percent of maximal PG) ranging from 0 to 31%. PG was < 50 mmHg in nine of 61 patients (15%) with a PG > 50 mmHg at the origin of the aorta when further measurements were conducted with the catheter positioned more distally in the ascending aorta. PR index better correlated with the ratio of valve area to ascending AO cross-sectional area (r = 0.61, p = 0.001) than with valve area (r = 0.37, p = 0.001) and ascending AO cross-sectional area (0.27, p = 0.02) alone. Differences between Doppler- and catheter-predicted PG were minimized when correcting Doppler by non-invasively calculated PR (p < 0.0001). CONCLUSION: The magnitude of PR recorded in aortic stenosis by FPC, as used in most clinical catheterization laboratories, is low in the vast majority of patients. As predicted from fluid mechanics theory, the ratio of valve area to ascending AO cross-sectional area is the central determinant of PR. PR may affect the Doppler-catheter correlation in some patients.