Left atrial strain is associated with long-term mortality in acute coronary syndrome patients.

To investigate the long-term prognostic value of the left atrial (LA) strain indices - peak atrial longitudinal strain (PALS), peak conduit strain (PCS), and peak atrial contractile strain (PACS) in acute coronary syndrome (ACS) patients in relation to all-cause mortality. This retrospective study included ACS patients treated with percutaneous coronary intervention (PCI) and examined with echocardiography. Exclusion criteria were non-sinus rhythm during echocardiography, missing images, and inadequate image quality for 2D speckle tracking analysis of the LA. The endpoint was all-cause death. Multivariable Cox regression which included relevant clinical and echocardiographic measures was utilized to assess the relationship between LA strain parameters and all-cause mortality. A total of 371 were included. Mean age was 64 years and 76% were male. Median time to echocardiography was 2 days following PCI. During a median follow-up of 5.7 years, 83 (22.4%) patients died. Following multivariable analysis, PALS (HR 1.04, 1.01-1.06, p = 0.002, per 1% decrease) and PCS (HR 1.05, 1.01-1.09, p = 0.006, per 1% decrease) remained significantly associated with all-cause mortality. PALS and PCS showed a linear relationship with the outcome whereas PACS was associated with the outcome in a non-linear fashion such that the risk of death increased when PACS < 18.22%. All LA strain parameters remained associated with worse survival rate when restricting analysis to patients with left atrial volume index < 34 ml/m2. Reduced LA function as assessed by PALS, PCS, and PACS were associated with an increased risk of long-term mortality in patients with ACS.

Organized thrombus is a frequent underlying feature in culprit lesion morphology in non-ST-elevation myocardial infarction. A study using optical coherence tomography and magnetic resonance imaging.

The concept that the culprit lesion in non-ST segment elevation myocardial infarction (NSTEMI) is caused by sudden plaque rupture with acute thrombus formation has recently been challenged. While angiography is an old gold-standard for culprit identification it merely visualizes the lumen contour. Optical coherence tomography (OCT) provides a detailed view of culprit features. Combined with myocardial edema on cardiac magnetic resonance (CMR), indicating acute ischemia and thus culprit location, we aimed to characterize culprit lesions using OCT. Patients with NSTEMI referred for angiography were prospectively enrolled. OCT was performed on angiographic stenoses ≥50% and on operator-suspected culprit lesions. Hierarchical OCT-culprit identifiers were defined in case of multiple unstable lesions, including OCT-defined thrombus age. An OCT-based definition of an organizing thrombus as corresponding to histological early healing stage was introduced. Lesions were classified as OCT-culprit or non-culprit, and characteristics compared. CMR was performed in a subset of patients. We included 65 patients with 97 lesions, of which 49 patients (75%) had 53 (54%) OCT-culprit lesions. The most common OCT-culprit identifiers were the presence of acute (66%) and organizing thrombus (19%). Plaque rupture was visible in 45% of OCT-culprit lesions. CMR performed in 38 patients revealed myocardial oedema in the corresponding territories of 67% of acute thrombi and 50% of organizing thrombi. A culprit lesion was identified by OCT in 75% patients with NSTEMI. Acute thrombus was the most frequent feature followed by organizing thrombus. Applying specific OCT-criteria to identify the culprit could prove valuable in ambiguous cases.

Echocardiographic Measures of Left Atrial Structure and Function and the Association with Atrial Fibrillation following Acute Coronary Syndrome.

INTRODUCTION: Acute coronary syndrome (ACS) is associated with an increased risk of developing atrial fibrillation (AF). This arrhythmia is associated with adverse outcomes, making it important to identify high-risk patients. The aim was to evaluate the prognostic value of measures of left atrial (LA) structure and function in AF prediction following ACS. METHODS: Three hundred and eighty-one patients who had a percutaneous coronary intervention for ACS were included in the study. Our endpoint was new-onset AF. RESULTS: With a median follow-up time of 5.4 [3.9-6.8] years, 56 patients (14.7%) developed AF. Patients developing AF had significantly (p ≤ 0.05) increased maximal and minimal LA volumes (LAVmax and LAVmin, respectively). LAVmax and LAVmin remained significantly increased in AF patients when indexing to either body surface area (LAVmax/BSA and LAVmin/BSA, respectively), left ventricle length in end diastole (LAVmax/LVLd and LAVmin/LVLd, respectively), or late mitral annular diastolic velocity (LAVmax/a' and LAVmin/a', respectively), while LA expansion index (LAEi), LA emptying fraction (LAEF), and peak LA longitudinal strain (PALS) were decreased. In univariable Cox regressions, all LA measures were found to be predictors of AF. After multivariable adjustment for clinical and echocardiographic parameters, all measures reflecting atrial function (LAVmin, LAVmin/BSA, LAVmin/LVLd, LAVmin/a', LAVmax/a', LAEF, LAEi, and PALS) (p ≤ 0.05) but no structural measures (LAVmax, LAVmax/BSA, and LAVmax/LVLd) remained significant independent predictors of AF. CONCLUSION: Echocardiographic measures of LA function are independent predictors of AF following ACS. Evaluation of LA function might improve the prognostic workup, aid in risk stratification for AF, and improve selection for further examinations.

Usefulness of left atrial strain for predicting incident atrial fibrillation and ischaemic stroke in the general population.

AIMS: Left atrial enlargement predicts incident atrial fibrillation (AF). However, the prognostic value of peak atrial longitudinal strain (PALS) for predicting incident AF in participants from the general population is currently unknown. Our aim was to investigate if PALS can be used to predict AF and ischaemic stroke in the general population. METHODS AND RESULTS: A total of 400 participants from the general population underwent a health examination, including two-dimensional speckle tracking echocardiography of the left atrium. The primary endpoint was incident AF at follow-up. All participants with known AF and prior stroke at baseline were excluded (n = 54). The secondary endpoint consisted of the composite of AF and ischaemic stroke. During a median follow-up of 16 years, 36 participants (9%) were diagnosed with incident AF and 30 (7%) experienced an ischaemic stroke, resulting in 66 (16%) experiencing the composite outcome. PALS was a univariable predictor of AF [per 5% decrease: hazard ratio (HR) 1.42; 95% confidence interval (CI) (1.19-1.69), P < 0.001]. However, the prognostic value of PALS was modified by age (P = 0.002 for interaction). After multivariable adjustment PALS predicted AF in participants aged <65 years [per 5% decrease: HR 1.46; 95% CI (1.06-2.02), P = 0.021]. In contrast, PALS did not predict AF in participants aged ≥65 years after multivariable adjustment [per 5% decrease: HR 1.05; 95% CI (0.81-1.35), P = 0.72]. PALS also predicted the secondary endpoint in participants aged <65 years and the association remained significant after multivariable adjustment. CONCLUSION: In a low-risk general population, PALS provides novel prognostic information on the long-term risk of AF and ischaemic stroke in participants aged <65 years.

Longitudinal change in cardiac structure and function following acute coronary syndrome according to culprit coronary artery lesion.

Acute coronary syndrome (ACS) may lead to adverse remodelling and impaired cardiac function. Limited data exists on the effect of culprit coronary artery lesion site and impact on longitudinal cardiac remodelling. The present study included a total of 299 patients suffering from ACS treated with percutaneous coronary intervention (PCI). All patients had two echocardiographic examinations. The first echocardiography was median 2(IQR: 1;3) days following PCI, while the follow-up echocardiography (FUE) was median 257(IQR: 96;942) days following the first. Patients were grouped based on coronary artery PCI location; left anterior descending artery (LAD), right coronary artery (RCA) or circumflex artery (Cx). Patients with multiple lesions were excluded. Mean age was 63 ± 11 years and 77% were male. At FUE, mean left ventricular ejection fraction was 42 ± 9% and global longitudinal strain (GLS) was - 13 ± 4%. PCI treatment was allocated as 168 LAD lesions, 95 RCA lesions, and 36 Cx lesions. Linear regression analysis showed that patients with a LAD lesion displayed worsening in E/A (mean ∆ = 0.05, ß = - 0.196, p = 0.001) and a larger increase in LVEDV (mean ∆ = 33.18 mL, ß = 0.135, p = 0.012). Meanwhile patients with Cx lesion were significantly associated with a larger decrease in E/e' (mean ∆ = 2.6, ß = - 0.120, p = 0.028). Patients with Cx lesion were observed to have elevated E/e' at baseline, which normalized at FUE. The present study suggests that culprit coronary artery lesion has a differential impact on myocardial remodelling. This information may potentially aid in understanding the pathophysiological differences in cardiac structure and function amongst patients with ACS.

Change in global longitudinal strain following acute coronary syndrome and subsequent risk of heart failure.

Global Longitudinal Strain (GLS) is a well-established predictor of heart failure (HF) following acute coronary syndrome (ACS). We aim to investigate the prognostic value of GLS obtained at a follow-up consultation, as well as the change in GLS for long-term risk of incident HF. A total of 235 ACS patients had an echocardiogram performed immediately after percutaneous coronary intervention (PCI) and a follow-up echocardiogram (FUE) median 215 (IQR: 71; 878) days after the first echocardiogram. Endpoint was incident HF. Follow-up time after FUE was median 4.8 (IQR: 3.7; 5.6) years. Patients diagnosed with HF before FUE were excluded. Mean age was 63 ± 11 years and 77% were male. Baseline GLS was on average 12.7 ± 3.9%, FUE GLS was on average 13.5 ± 3.9% and mean improvement in GLS was 0.73 ± 3.68% between the 2 echocardiograms. A total of 57 (24%) patients suffered incident HF following the FUE. FUE GLS provided significantly higher prognostic information for risk of incident HF than ∆GLS when assessed by the C-statistics (C-statistics: 0.71 vs. 0.61, P = 0.021). Furthermore, after multivariable adjustments only FUE GLS [HR = 1.15, 95% CI (1.02; 1.29), P = 0.018, per 1% decrease] remained an independent predictor of incident HF. In patients with ACS, who do not develop HF before FUE, FUE GLS was an independent predictor of long-term risk of incident HF while ∆GLS was not.

A Validated Echocardiographic Risk Model for Predicting Outcome Following ST-segment Elevation Myocardial Infarction.

Many echocardiographic measures have been proposed as potential predictors of outcome following ST-elevation myocardial infarction (STEMI). We hypothesized that combining multiple echocardiographic measures in a risk model provides more prognostic information than individual echocardiographic measures. We prospectively included 373 STEMI patients which constituted our derivation cohort. We also identified 298 STEMI patients from a clinical registry that constituted our validation cohort. Echocardiogram was performed at a median of 2 days after infarction. The echocardiogram consisted of conventional and advanced measures. The end point was a composite of heart failure and/or cardiovascular death. During a median follow-up of 5.4 years, we observed 80 events in our derivation cohort. A stepwise backward Cox regression including all echocardiographic parameters identified global longitudinal strain, wall motion score index (WMSI), E/e', and E/global strain rate e (E/GLSRe) as significant predictors of outcome. A Classification and Regression Tree analysis outlined a risk model with WMSI, GLSRe, and E/e' as key echocardiographic parameters. Patients with WMSI ≥ 2.22 were at high risk, patients with WMSI < 2.22, GLSRe < 0.82s-1 and E/e'≥7.6 at intermediate risk, and patients with WMSI < 2.22 and GLSRe ≥ 0.82s-1 or GLSRe < 0.82s-1 and E/e' < 7.6 at low risk of heart failure and/or cardiovascular death. When compared with the low-risk group, an incremental risk was observed (intermediate group: HR = 2.52 [1.24;5.11], p = 0.011; high-risk group: HR = 4.37 [1.40;13.66], p = 0.011). The risk model was validated in the validation cohort (C-statistic: 0.71). In conclusion, we devised an echocardiographic risk model for STEMI patients suggesting advanced and conventional measures of systolic function and filling pressures to be important for the prognosis.

Post-systolic shortening predicts heart failure following acute coronary syndrome.

BACKGROUND: Post-systolic shortening (PSS) is a novel echocardiographic marker of myocardial dysfunction. Our objective was to assess the prognostic value of PSS in patients following acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). METHODS: A total of 428 patients hospitalized for ACS (mean age 64 ±â€¯12 years, male 73%) underwent speckle tracking echocardiography following treatment with PCI (median 2 days). The individual endpoints were heart failure (HF), myocardial infarction (MI) and all-cause death. We excluded known HF. Presence of PSS was defined as post-systolic displacement ≥20% of maximum strain in one cardiac cycle. The post-systolic index (PSI) was defined as (100 × [maximum-strain cardiac cycle - peak-systolic strain])/(maximum-strain cardiac cycle)]. RESULTS: During median follow-up of 3.7 years (IQR 0.3, 5.2), 155 patients (36%) experienced HF, 52 (12%) had MI and 87 (20%) died from all causes. Patients experiencing HF had more walls displaying PSS (3.2 vs. 1.9 walls) and higher PSI (22% vs. 12%) (P < 0.001 both). In Cox proportional hazards models adjusted for baseline characteristics, invasive and echocardiographic measurements, the risk of HF increased incrementally with increasing number of walls with PSS (HR 1.28 95%CI 1.12-1.46, P < 0.001 per 1 increase in walls with PSS). The PSI remained an independent predictor of HF after adjustment (HR 1.61 95%CI 1.21-2.12, P = 0.001 per 1% increase). In the same adjusted models, MI and all-cause death were not significantly associated with PSS. CONCLUSION: Presence of PSS provides novel and independent prognostic information regarding the risk of future HF in patients with ACS following PCI.

Pooled Analysis Comparing the Efficacy of Intracoronary Versus Intravenous Abciximab in Smokers Versus Nonsmokers Undergoing Primary Percutaneous Coronary Revascularization for Acute ST-Elevation Myocardial Infarction.

Cigarette smokers with ST-segment elevation myocardial infarction (STEMI) may present different response to potent antithrombotic therapy compared to nonsmokers. We assessed the impact of smoking status and intracoronary abciximab in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). We pooled data from 5 randomized trials comparing intracoronary versus intravenous abciximab bolus in patients undergoing primary PCI. The primary end point was the composite of death or reinfarction at a mean follow-up of 292 ± 138 days. Of 3,158 participants, 1,369 (43.3%) were smokers, and they had a lower risk of the primary end point in crude, but not in adjusted analyses (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.63 to 1.21, p = 0.405). Intracoronary versus intravenous abciximab was associated with a significant reduction in the risk of primary end point among smokers (3.6% vs 8.0%; HR 0.43, 95% CI 0.26 to 0.72, p = 0.001), but not in nonsmokers (10.2% vs 9.9%; HR 0.99, 95% CI 0.72 to 1.36, p = 0.96), with a significant interaction (p = 0.009). Furthermore, intracoronary abciximab decreased the risk of reinfarction in smokers (HR 0.30, 95% CI 0.15 to 0.62, p = 0.001), with no difference in nonsmokers (HR 1.20, 95% CI 0.71 to 2.01, p = 0.50). Stent thrombosis was lowered by intracoronary abciximab in smokers (HR 0.28, 95% CI 0.06 to 0.66, p = 0.009), but was ineffective in nonsmokers (HR 1.04, 95% CI 0.54 to 2.00, p = 0.903). Interaction testing showed heterogeneity in treatment effect for reinfarction (p = 0.002) and stent thrombosis (p = 0.018) according to smoking status. In conclusion, among patients with STEMI undergoing primary PCI, smoking status did not affect the adjusted risk of clinical events. Intracoronary abciximab bolus improved clinical outcomes by reducing the risk of death or reinfarction.

1-Year Outcomes With Intracoronary Abciximab in Diabetic Patients Undergoing Primary Percutaneous Coronary Intervention.

BACKGROUND: Diabetic patients are at increased risk for future cardiovascular events after ST-segment elevation myocardial infarction (STEMI). Administration of an intracoronary abciximab bolus during primary percutaneous coronary intervention (PCI) may be beneficial in this high-risk subgroup. OBJECTIVES: This study sought to report the 1-year clinical outcomes and cardiac magnetic resonance (CMR) findings in STEMI patients with and without diabetes randomized to intracoronary or intravenous abciximab bolus at the time of primary PCI. METHODS: Patient-level data from 3 randomized trials were pooled. The primary endpoint was the composite of death or reinfarction. Comprehensive CMR imaging was performed in 1 study. RESULTS: Of 2,470 patients, 473 (19%) had diabetes and 1,997 (81%) did not. At 1 year, the primary endpoint was significantly reduced in diabetic patients randomized to intracoronary abciximab compared with those randomized to intravenous bolus (9.2% vs. 17.6%; hazard ratio [HR]: 0.49; 95% confidence interval [CI]: 0.28 to 0.83; p = 0.009). The intracoronary abciximab bolus did not reduce the primary endpoint in patients without diabetes (7.4% vs. 7.5%; HR: 0.95; 95% CI: 0.68 to 1.33; p = 0.77), resulting in a significant interaction (p = 0.034). Among diabetic patients, intracoronary versus intravenous abciximab bolus was associated with a significantly reduced risk of death (5.8% vs. 11.2%; HR: 0.51; 95% CI: 0.26 to 0.98; p = 0.043) and definite/probable stent thrombosis (1.3% vs. 4.8%; HR: 0.27; 95% CI: 0.08 to 0.98; p = 0.046). At CMR (n = 792), the myocardial salvage index was significantly increased only in diabetic patients randomized to intracoronary compared with intravenous abciximab (54.4; interquartile range: 35.1 to 78.2 vs. 39.0, interquartile range: 24.7 to 61.7; p = 0.011; p for interaction vs. no diabetes = 0.016). CONCLUSIONS: In diabetic patients with STEMI, the administration of intracoronary abciximab improved the effectiveness of primary PCI compared with the intravenous bolus.

Intracoronary abciximab in diabetic patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Although intracoronary abciximab failed to improve prognosis compared with intravenous route in unselected ST-segment elevation myocardial infarction (STEMI) patients, little is known about the role of intracoronary abciximab in diabetic patients. OBJECTIVES: To evaluate the efficacy of intracoronary abciximab administration in diabetic patients with STEMI undergoing primary percutaneous coronary intervention (PCI). METHODS: Reperfusional and clinical outcomes of intracoronary abciximab compared with intravenous bolus abciximab according to diabetic status were evaluated in a pooled analysis of five randomized trials including 3158 STEMI patients. The primary clinical endpoint of the study was the composite of death or reinfarction at 30-day follow-up. RESULTS: Among 584 diabetic patients (18.5%), the composite of death or reinfarction was significantly reduced with intracoronary abciximab compared to intravenous abciximab (4.7% vs. 8.8%; rate ratio [RR], 0.50; 95% confidence intervals [CI], 0.26-0.99; p=0.04), driven by numerically lower deaths (3.7% vs. 6.4%; RR, 0.56; 95% CI, 0.26-1.20; p=0.13). Moreover, a significant reduction in definite or probable stent thrombosis was observed in patients receiving intracoronary abciximab (1% vs. 3.5%; RR, 0.27; 95% CI, 0.07-0.99; p=0.04). Although formal tests for interaction were not significant, no clinical benefit was apparent in the cohort of STEMI patients without diabetes (n=2574). CONCLUSIONS: In diabetic patients with STEMI undergoing primary PCI, intracoronary abciximab may improve clinical outcomes as compared with standard intravenous use. These findings require confirmation in a dedicated randomized trial.

Effects of baseline coronary occlusion and diabetes mellitus in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Several studies have highlighted the prognostic role of preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow in the infarct-related artery (IRA) in patients with ST-segment elevation myocardial infarction (STEMI). However, the impact of preprocedural IRA occlusion in patients with diabetes with STEMI has been insufficiently studied. The aim of this study was to evaluate the effects of baseline IRA occlusion and diabetic status in patients with STEMI who underwent primary percutaneous coronary intervention by using data from a pooled analysis of randomized trials comparing intracoronary with intravenous abciximab bolus administration. A total of 3,046 patients with STEMI who underwent primary percutaneous coronary intervention were included. Diabetes was present in 578 patients (19%). The primary outcome was mortality after a median follow-up period of 375 days. Secondary end points were reinfarction and stent thrombosis. In patients without diabetes, IRA occlusion versus no occlusion was not associated with increased rates of mortality (4.3% vs 2.7%, p = 0.051) and reinfarction (3.3% vs 2.5%, p = 0.33). Patients with diabetes with IRA occlusion compared with those without occlusion showed higher rates of mortality (10.6% vs 4.6%, p = 0.01) and reinfarction (5.6% vs 2.1%, p = 0.03). Baseline IRA occlusion increased the rate of stent thrombosis in the nondiabetic (2.1% vs 1.0%, p = 0.04) and diabetic (3.2% vs 0.8%, p = 0.05) cohorts. Interaction analysis demonstrated that the risk for death and reinfarction was significantly increased when diabetes and IRA occlusion occurred concomitantly. In conclusion, patients with STEMI with diabetes and baseline IRA occlusion had disproportionately higher rates of death and reinfarction. Preprocedural IRA occlusion increased the risk for stent thrombosis, irrespective of diabetic status.

Unmet needs of young interventional cardiologists: proceedings from the 2nd summit of the European association of percutaneous cardiovascular interventions.

Every year, the EAPCI Board invites presidents and representatives of the interventional working groups affiliated to EAPCI to discuss issues and strategies surrounding the goals of education and advanced healthcare practices in interventional cardiology. In 2013, the 2nd EAPCI Summit, organised by the EAPCI Board in collaboration with the NIFYI committee, was entirely dedicated to discussing the unmet needs of the young generation of interventional cardiologists. In this article, we highlight a selection of the key points and proposed actions highlighted during the summit.

Intracoronary versus intravenous bolus abciximab administration in patients undergoing primary percutaneous coronary intervention with acute ST-elevation myocardial infarction: a pooled analysis of individual patient data from five randomised controlled trials.

AIMS: In recent years, intracoronary bolus abciximab has emerged as an alternative to the standard intravenous route in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). The aim of the current study was to perform an individual patient-level pooled analysis of randomised trials, comparing intracoronary versus intravenous abciximab bolus use in STEMI patients undergoing primary PCI. METHODS AND RESULTS: Individual data of 3,158 patients enrolled in five trials were analysed. Reperfusion endpoints were: post-procedural Thrombolysis in Myocardial Infarction (TIMI) 3 flow, myocardial blush grade (MBG) 2/3 and complete ST-segment resolution. The primary clinical endpoint of interest was the composite of death and reinfarction at 30 days. Compared with the intravenous route, intracoronary abciximab bolus administration did not improve TIMI 3 flow (odds ratio [OR] 1.19; 95% confidence interval [CI]: 0.90-1.59; p=0.23) and complete ST-segment resolution (OR 1.22, 95% CI: 0.92-1.63, p=0.17), but increased MBG 2/3 occurrence (OR 1.83, 95% CI: 1.05-3.18, p=0.03). At 30-day follow-up, intracoronary bolus abciximab did not reduce the risk of death and reinfarction (OR 0.78, 95% CI: 0.55-1.10, p=0.16), death (OR 0.77, 95% CI: 0.51-1.17, p=0.22), reinfarction (OR 0.79, 95% CI: 0.46-1.33, p=0.38) and stent thrombosis (OR 0.77, 95% CI: 0.43-1.35, p=0.36) as compared with intravenous administration. CONCLUSIONS: In STEMI patients undergoing primary PCI, intracoronary abciximab does not provide additional benefits as compared with standard intravenous treatment and, therefore, it should not be recommended as the default route of administration in this setting.

Clinical impact of intracoronary abciximab in patients undergoing primary percutaneous coronary intervention: an individual patient data pooled analysis of randomised studies.

OBJECTIVES: The aim of this study was to perform an individual patient-level pooled analysis of randomised trials, comparing intracoronary versus intravenous abciximab bolus use in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: Abciximab represents a cornerstone in the treatment of STEMI patients undergoing primary PCI. Intracoronary abciximab bolus administration has been proposed as an alternative strategy to the standard intravenous route. However, whether intracoronary abciximab effectively improves clinical outcomes compared with standard route remains unknown. METHODS: Individual data of 1198 patients enrolled in five trials were entered into the pooled analysis. The primary endpoint of the study was the occurrence of all-cause death and reinfarction at 30-day follow-up. Secondary endpoints were all-cause death, reinfarction and target-vessel revascularisation (TVR). RESULTS: No significant heterogeneity was found across trials. Compared with the intravenous route, intracoronary abciximab administration significantly reduced the risk of the composite of death and reinfarction (HR 0.52, 95% CI 0.29 to 0.94; p=0.03), death (HR 0.44, 95% CI 0.20 to 0.95; p=0.04) and TVR (HR 0.53, 95% CI 0.29 to 0.99; p=0.045), without a significant impact on the risk of reinfarction (HR 0.54, 95% CI 0.24 to 1.21; p=0.13). However, after correction for baseline differences, only the composite of death/reinfarction and death remained significant. CONCLUSIONS: In STEMI patients undergoing primary PCI, intracoronary abciximab administration, when compared with the intravenous standard route, can improve short-term clinical outcomes mainly by reducing the risk of death.

Tissue Doppler echocardiography improves the diagnosis of coronary artery stenosis in stable angina pectoris.

UNLABELLED: Aim To determine if colour tissue Doppler imaging (TDI) performed at rest in patients with suspected stable angina pectoris (SAP) is able to predict the presence of significant coronary artery disease (CAD). METHODS AND RESULTS: This study comprises 296 consecutive patients with clinically suspected SAP, no previous cardiac history, and a normal ejection fraction. All patients were examined by colour TDI, exercise electrocardiogram (ECG), and coronary angiography (CAG). Regional longitudinal systolic (s'), early diastolic (e'), and late diastolic (a') myocardial velocities were measured by colour TDI at six mitral annular sites and averaged to provide global estimates. Duke score (DS), including ST depression, chest pain, and exercise capacity, was used as the outcome of the exercise ECG. Patients with an area stenosis of ≥70% in at least one epicardial coronary artery were categorized as having a significant CAD (n= 108) and were compared with patients without significant CAD (n= 188). Both e' [odds ratio (OR): 1.5 (1.1-1.9, P < 0.01) per cm/s decrease] and s' [OR: 1.7 (1.1-2.5, P < 0.05) per cm/s decrease] remained independent predictors of CAD after multivariable adjustment for baseline, exercise ECG, and conventional echocardiographic parameters. Area under the receiver operating characteristic curve (AUC) for exercise ECG and TDI in combination was significantly higher than AUC for exercise ECG alone (0.84 vs. 0.79, P < 0.01). CONCLUSION: In patients with suspected SAP colour TDI performed at rest is an independent predictor of significant CAD, and colour TDI improves the diagnostic performance of exercise ECG.

Significance of the invasive strategy after acute myocardial infarction on prognosis and secondary preventive medication: a nationwide study of 6364 women and 11,915 men.

OBJECTIVE: To describe gender-specific long-term outcome and initiation of secondary preventive medication among patients with acute myocardial infarction (AMI). DESIGN: Observational cohort study. SETTING: Nationwide registries. PATIENTS: We included 18,279 patients: 6364 women (35%) and 11,915 men (65%), admitted with AMI (median age, 67 years; range, 30-90 years) surviving for at least 2 months. INTERVENTIONS: According to sex, patients were stratified by invasive treatment strategy: (1) revascularized; (2) examined with coronary angiography (CAG) but not revascularized; and (3) not examined with CAG. MAIN OUTCOME MEASURES: All-cause mortality and readmission with AMI. Initiation of secondary preventive medication. RESULTS: Of 18,279 patients with a first AMI who survived 2 months, 1857 women (29%) and 1756 men (15%) were not examined with CAG (P<.001), 1295 women (20%) and 1563 men (13%) were examined but not revascularized (P<.001), and 3212 women (51%) and 8596 men (72%) were revascularized (P<.001). Not being examined with CAG after AMI was associated with a three-fold increase in risk of death and, importantly, a 50% increase in the risk of a recurrent AMI compared with patients who were revascularized. Among patients who were revascularized, 85-92% initiated recommended secondary preventive medication compared to 46-71% in patients not examined with CAG (P<.001). Initiation of secondary preventive medication was higher in men (81-84%) than in women (73-79%; P<.001), which could be ascribed to the differences in invasive strategy. CONCLUSIONS: In both sexes, those who were not examined had a highly increased risk of both recurrent AMI and death. Moreover, initiation of secondary preventive medication was closely related to the choice of invasive strategy disfavoring the women.

Intracoronary compared to intravenous abciximab in patients with ST segment elevation myocardial infarction treated with primary percutaneous coronary intervention reduces mortality, target vessel revascularization and reinfarction after 1 year.

OBJECTIVES: Administration of the glycoprotein IIb/IIIa inhibitor abciximab to patients with ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) improves outcome. Data have suggested that an intracoronary (IC) bolus might be superior to the standard intravenous (IV) administration. We have previously reported reduced short-term mortality and need for target vessel revascularization (TVR) with the IC route. We now present long-term data from our randomized trial on IC versus IV abciximab in pPCI-treated STEMI patients. METHODS: A total of 355 pPCI-treated STEMI patients were randomized to either IC or IV bolus abciximab followed by a 12-hour IV infusion. Patients were followed for 1 year to observe mortality, TVR or myocardial infarction (MI) and the combination of these. RESULTS: The two treatment arms (IV, n = 170; IC, n = 185) were similar with regard to baseline characteristics. Mortality was reduced from 10% in the IV group to 2.7% in the IC group (p = 0.004). TVR and MI were also reduced with IC administration (TVR: 14.1 vs. 7.6%, p = 0.04; MI: 11.8 vs. 5.4%, p = 0.03). Consequently, patients in the IC treatment arm had a relative risk reduction of 55% for the combined endpoint after 1 year (p = 0.002) compared to the IV treatment arm. CONCLUSIONS: In pPCI-treated STEMI patients treated with abciximab, IC bolus administration resulted in a significant reduction in mortality, TVR and MI compared to IV bolus administration.