Short-term outcome and attainment of secondary prevention goals in patients with acute coronary syndrome--results from the countrywide TARGET study.

BACKGROUND/OBJECTIVES: Acute coronary syndromes (ACS) continue to pose a significant medical and socioeconomic burden worldwide. Optimal management strategy aims to improve short and long-term outcome. The present study aims to assess short-term outcome of real-world ACS patients and evaluate the achievement rate of secondary prevention goals. METHODS: The TARGET study is an observational study enrolling 418 consecutive ACS patients from 17 centers countrywide (78.0% males, 63.9 ± 12.9 years). After the in-hospital phase, patients were followed for 6 months. In total, 366 patients were included in the prospective phase of the study. At the end of the follow-up, mortality, major adverse cardiovascular events (MACE), prescription pattern of cardiovascular medications, lipid levels, adherence rate to treatment and behavioral recommendations were measured. RESULTS: The overall mortality was 4.8% and the rate of MACE was 17.5%. At 6 months, a significantly lower proportion of patients received antiplatelet agents and statins as compared to hospital discharge. At the end of the follow-up, 87.7% of patients remained on statin treatment, yet only 18.2% of patients had LDL cholesterol levels less than 70 mg/dL. The adherence pattern to lifestyle and dietary recommendations remained low (66.2% quit smoking, 55.8% and 81.3% followed physical activity and dietary recommendations respectively). CONCLUSION: Despite the low rate of mortality and MACE occurrence rate in this countrywide observational study, the attainment rate of secondary prevention goals is relatively poor. Improvement interventions focusing in these gaps of optimal care provision are expected to have a favorable impact on the prognosis of real world ACS patients.

Tomato pollen respiration in relation to in vitro germination and pollen tube growth under favourable and stress-inducing temperatures.

Tomato pollen germination, pollen tube growth and respiratory activity were recorded during incubation in a liquid medium for 7 h over a temperature range of 15-35 degrees C. Although the initial rate of respiration was highest at 30 degrees C, both at 30 degrees C and 35 degrees C respiration decreased after the first hour of incubation due to high temperature impairment of germination and pollen tube growth. The total per cent germination of pollen over the 7-h period was maximal at 15 degrees C whereas pollen tube length was maximal at 25 degrees C. Although the production of CO(2) measured at hourly intervals throughout the incubation period did not correlate to a statistically significant level with either the per cent pollen germination or the length of the pollen tubes alone, nevertheless from 2 h after the start of incubation, it closely correlated with the values for germination x pollen tube length, indicating that the respiratory activity of tomato pollen at a given time is a function of both the per cent germination and the pollen tube growth. We suggest therefore that the rate of respiration might be preferable to a simple germination test for the assessment of pollen germination ability since it expresses not only the pollen germination potential but also the growth vigour of the pollen tubes. In addition, where in vitro tests are designed to assess pollen germination-temperature interactions, they should employ a long incubation period (e.g. 7 h) to permit differences in sensitivity to temperature to be observed.

The effect of substrate, ADP and uncoupler on the respiration of tomato pollen during incubation in vitro at moderately high temperature.

Pollen of tomato cv. Supermarmande was collected from greenhouse-grown plants at various intervals throughout the year and arbitrarily classified as of high, medium or low respiratory activity on the basis of CO(2) production during 8 h incubation in vitro at 30 degrees C, a temperature that is considered to be moderately high for tomato fruit set. After an initial burst of respiration during the first stage of hydration at 30 degrees C (>1 h), the respiration rate of pollen of all three categories declined, the decrease being greater in the lots with a low or medium respiratory activity than in the high category. During hydration (10 min after the start of incubation), the addition of succinate or reduced beta-nicotinamide adenine dinucleotide (NADH) to the substrate increased the respiratory rate of slowly-respiring pollen more than that of fast-respiring pollen, but carbonyl cyanide 3-chlorophenylhydrazone (CCCP) and adenosine 5'-diphosphate (ADP) had less effect. After 1-4 h incubation, the respiration rate of the slow- or medium-respiring pollen lots had decreased, but was stimulated by succinate or NADH, and to a lesser degree by ADP. By 7 h, the respiration rate of all pollen lots had declined and was stimulated less by substrate, ADP or CCCP. The oxidation of NADH by tomato pollen contrasts with the failure of other pollen species to utilize this substrate; moreover, a synergistic effect of NADH and succinate was consistently observed. We conclude that the decline in respiration during incubation for up to 4 h at 30 degrees C may reflect a lack of respiratory substrate. After 7 h, however, the decreased response to substrate indicates a loss of mitochondrial integrity or an accumulation of metabolic inhibitors. It is concluded that at 30 degrees C (a moderately high temperature for tomato pollen), the initially high rate of respiration leads to exhaustion of the endogenous respiratory substrates (particularly in pollen with low to medium respiratory activity), but subsequently to ageing and a loss of mitochondrial activity.

The significance of circulating levels of both cardiac troponin I and high-sensitivity C reactive protein for the prediction of intravenous thrombolysis outcome in patients with ST-segment elevation myocardial infarction.

OBJECTIVES: To evaluate, using continuous 12-lead ECG ST-segment monitoring, the role of circulating levels of both cardiac troponin I (cTnI) and high-sensitivity C reactive protein (hs-CRP), on presentation, in the prediction of intravenous thrombolysis outcome in patients with ST-segment elevation myocardial infarction (STEMI). DESIGN AND SETTING: Prospective observational study in a tertiary referral centre. PATIENTS: 786 consecutive patients with STEMI, who received intravenous thrombolysis in the first 6 h from index pain. MAIN OUTCOME MEASURES: The incidence of failed thrombolysis and of cardiac death by 30 days. Failed thrombolysis was defined as the absence of abrupt and sustained > or =50% ST-segment recovery in the first 90 min after the initiation of intravenous thrombolysis. RESULTS: The incidence of failed thrombolysis and 30-day cardiac death was 57.4% and 11.8%, respectively. By multivariate logistic regression analysis according to tertiles of both cTnI (RR, 1.5; 95% CI 1.1 to 1.8, p = 0.004 for highest vs middle third; 2.2, 1.9 to 3.5, p<0.001 for highest vs lowest third; 1.5, 1.2 to 1.8, p = 0.001 for middle vs lowest third) and hs-CRP (RR, 2.0, 95% CI, 1.6 to 2.2; p<0.001 for highest vs middle third; 2.6, 2.1 to 3.5, p<0.001 for highest vs lowest third; 1.3, 1.2 to 1.7, p = 0.02 for middle vs lowest third), were independently associated with failed thrombolysis. Moreover, by multivariate Cox regression analysis according to tertiles of both cTnI (HR 1.2, 95% CI 1.1 to 1.8, p = 0.03 for highest vs middle third; 1.5, 1.2 to 2.2, p = 0.004 for highest vs lowest third; 1.1, 0.6 to 1.4, p = 0.6 for middle vs lowest third) and hs-CRP (HR1.2, 95% CI 1.1 to 1.6, p = 0.04 for highest vs middle third; 1.7, 1.3 to 2.6, p = 0.001 for highest vs lowest third; 1.1, 0.9 to 2.1, p = 0.1 for middle vs lowest third), were independently related with an increased risk of 30-day cardiac death. CONCLUSIONS: High circulating levels of both cTnI and hs-CRP are related with an independent increased risk of intravenous thrombolysis failure and 30-day cardiac death in patients who received intravenous thrombolysis in the first 6 h of STEMI.

Antiplatelet is superior to anticoagulant treatment after coronary stenting: fewer coronary and other events within 30 days after stenting.

Stent prosthesis is a high efficacious method with low complication rates. However, the ideal adjunctive therapy following stent implantation remains controversial. The authors compared the effectiveness and complication rates of aspirin-ticlopidine antiplatelet therapy vs. anticoagulant therapy with acenocoumarol within 30 days following stent prosthesis. They prospectively studied 404 patients following stent prosthesis while randomly receiving anticoagulant (Group A: 201 patients) vs. antiplatelet treatment (Group B: 203 patients). Groups A and B were similar in demographic data (age, gender), stent location, clinical presentation, indication of stenting, and type of implanted stent. Chi-square test, t test, and Wilcoxon test for two samples were used for statistical analysis of the results. Stent implantation was attempted in 434 cases. This was successful in 70/85 (82%) of the bailout, 122/135 (90%) of the suboptimal, and 212/214 (99%) of the elective cases. In 201 patients anticoagulant treatment with acenocoumarol was administered for 4 weeks (group A), while 203 received antiplatelet treatment with ticlopidine (group B). The need for reintervention was less and total cardiac events were fewer in group B than in group A: three (1.5%) and nine (4.4%) vs 18 (9%) and 29 (14.4%), p<0.0008 and p<0.006 respectively. Hemorrhagic complications and total noncardiac events were fewer in group B than in group A: six (3%) and six (3%) vs. 18 (9%) and 19 (9.5%), p<0.01 and p<0.007 respectively. The length of hospital stay was shorter in group B than in A, p<0.0001. In conclusion, in this study of intracoronary stenting the authors had a high success rate in 434 attempted cases. Antiplatelet therapy was accompanied by fewer cardiac and noncardiac 1 month events when compared with anticoagulant therapy, supporting its role as the adjunctive treatment of choice post-stenting for the time being.

Chronic sympathetic suppression in the treatment of chronic congestive heart failure.

Previous short-term studies demonstrated that treatment with clonidine produced significant hemodynamic improvement in patients with congestive heart failure (CHF). In this study we followed 12 CHF patients (10 M, 2 F age 63+/-11, 10 with ischemic cardiomyopathy and 2 with dilated cardiomyopathy) treated with 0.15 or 0.075 mg oral clonidine twice daily for 13+/-5 months (range 6-23). with functional evaluation at baseline, 6 weeks and 6 months. There was suppression of circulating catecholamines, associated with significant ameliorations in NYHA class, in duration of exercise tolerance (from 246+/-68 sec to 362+/-30 and 459+/-70 sec, respectively p < 0.02), in ejection fraction (from 32+/-7% to 35+/-5 and 39+/-7% p < 0.04) and in left ventricular enlargement as assessed echocardiographically. There were also improvements in a number of electrophysiologic parameters calculated by computerized analysis of ambulatory ECG tapes, such as heart rate variability, indicating diminished propensity to malignant arrhythmias, as confirmed by decreases in the numbers of isolated premature ventricular contractions, couplets and episodes of non-sustained ventricular tachycardia. The data suggest that chronic central sympathetic suppression with clonidine in CHF results in significant functional amelioration and improved electrophysiologic stability.

Clinical characteristics and follow-up of patients with chest pain and normal coronary arteries.

The authors identified 160 men and women from all 3,700 patients with anginal pain between 1990 and 1994 who were subsequently found to have normal coronary arteries at diagnostic cardiac catheterization with follow-up to the present (mean follow-up 2.5 years). The group comprised 50 women and 110 men. Mean age was significantly greater in women (53.1 +/- 7.7 vs 47.2 +/- 9.2 years, p<0.001). Forty percent of the women but only 10% of the men had a positive exercise test. At follow-up, a larger proportion of patients continue to experience chest pain (95 patients, 59%) of whom 65 patients (41%) continue antianginal therapy. Furthermore one patient suffered a sudden cardiac death and two patients had a nonfatal myocardial infarction. Of patients referred with chest pain, women were more likely to have normal coronary arteries, compared with men. All patients have an excellent prognosis. A large proportion of women had a positive exercise test in the absence of coronary artery disease. On the other hand, morbidity remains high in these patients, despite the reassurance of a normal-appearing coronary arteriogram.

The natural history of aneurysmal coronary artery disease.

OBJECTIVE: To assess the contribution of coronary artery ectasia, either isolated or in association with obstructive coronary artery disease, to morbidity and mortality from ischaemic heart disease. DESIGN: A retrospective study of patients undergoing coronary arteriography at a tertiary cardiac centre. PATIENTS AND METHODS: The epidemiological, clinical, arteriographic, and follow up characteristics of three groups of patients were examined: group A, 172 patients with coronary artery ectasia and coexisting significant coronary artery disease; group B, 31 patients with coronary artery ectasia only; group C, 165 patients with significant coronary artery disease but without ectasia, matched for sex and age with group A. RESULTS: Group A patients had a similar incidence of a previous myocardial infarction to group C patients (61.6% v 64.2%), exercise performance, severity of obstructive lesions (CASS score 2.19 v 2.14), and similar distribution of diseased vessels. At follow up of approximately two years they experienced a similar incidence of unstable angina (7.5% v 4.4%) and myocardial infarction plus cardiac death (4.9% v 6.1%). They underwent bypass surgery with similar frequency (39% v 42%) but there was a lower frequency of percutaneous transluminal coronary angioplasty (5.8% v 17%, P < 0.01). Patients with pure coronary ectasia (group B) had a lower incidence of a previous myocardial infarction (38.7%, 12/31, P < 0.05) than the two other groups. The infarct in all cases was related to an ectatic artery. Their exercise performance and ejection fraction (9 (SD 3) minutes and 56.5(9)%) were higher (P < 0.01) than group A (5 (2) minutes, 48.3(10)%) and group C (5.3 (2) minutes, 49.3(10)%). Group B had no myocardial infarctions, cardiac death, surgery, or intervention at follow up; 4.4% (5/115) developed unstable angina. The incidence of angina at study entry was similar in all three groups (38.7-49.7%). CONCLUSIONS: Coronary artery ectasia does not confer added risk in patients with coexisting obstructive coronary artery disease. Although there is a measurable incidence of previous myocardial infarction, patients with pure ectasia have a good prognosis. The wisdom of giving oral anticoagulants to such patients is questioned.

Combined sympathetic suppression and angiotensin-converting enzyme inhibition in congestive heart failure.

Neurohormonal activation is a pathogenic contributor and prognostic marker in congestive heart failure (CHF). While angiotensin-converting enzyme (ACE) inhibition is now first-line therapy, sympathetic inhibition has only lately been proposed to this aim. Recently, we reported improvement of preload parameters by sympathetic suppression with clonidine. In the present paper we studied the effects of a single oral dose of clonidine 0.15 mg+captopril 6.25 mg combination, compared with captopril 6.15+placebo in a single-blind parallel study on 16 patients with Class III or IV CHF (13 males, 3 females, aged 62 +/- 8 years, with an ejection fraction of 33 +/- 8%). Hemodynamic and hormonal measurements were taken at baseline after a diagnostic cardiac catheterization and again 2 hours after treatment. The results indicate that preload parameters such as RAP, PCWP and MPAP decreased significantly with the combination therapy but not with captopril alone. On the contrary, SVR decreased significantly with both treatments and SVI increased significantly with both-but the latter change was significantly greater with the captopril/clonidine combination than with captopril alone. Suppression of plasma norepinephrine occurred with the combination only (evidently attributable to clonidine), whereas plasma renin activity increased with both regimens, due apparently to captopril. Our results indicate that the combination of clonidine with captopril induces significant improvements in both preload and afterload parameters of CHF and correction of activated neurohormones, suggesting additive hemodynamic and hormonal benefits from the two treatment modalities.

Postinfarction ventricular septal rupture following thrombolysis: long-term survival in the presence of normal coronary arteries. A case report.

A case of postinfarction ventricular septal rupture in a thrombolyzed patient is described. Coronary angiography revealed normal coronary arteries. The interrelations of long-term survival of postinfarction ventricular septal rupture, thrombolysis, and normal coronary arteries are discussed.

Hyperventilation test in syndrome X.

The hyperventilation (HV) test has been extensively used in different forms of coronary artery disease. The purpose of this work was to investigate the response to HV in patients with syndrome X and compare HV with exercise (EX) test. The authors studied 20 patients with syndrome X (angina, a positive EX test, and normal coronary angiogram) and 20 healthy subjects who underwent HV and EX tests. In 7 patients, all women, angina and electrocardiographic (ECG) changes occurred during HV but in none of the controls. Patients with syndrome X and controls had a similar rate-pressure product (RPP) at rest and achieved a similar RPP with HV. The RPP achieved with HV in patients with syndrome X without ECG changes was significantly lower, 121.8 +/-29.1(mean +/-SD), than what was achieved by those with changes, 167.9 +/-42.9, P < 0.01. In patients with an abnormal response to HV the RPP at which angina and ECG changes occurred was similar to that where similar changes were observed during EX. There was a significant correlation of the RPPs between the two tests, r=0.82, P < 0.02. In contrast, in patients in whom no angina or ECG changes occurred, the RPP they achieved with HV was significantly lower than the anginal threshold during EX 204 +/- 47.4, P < 0.0001. In conclusion, a significant proportion of patients with syndrome X, mainly women, who achieve a high RPP with HV, develop angina and ECG changes during overbreathing. The close relation between EX and HV RPPs where these changes occur suggests an increased myocardial oxygen demand as the most likely underlying mechanism for this behavior.

Suppressing sympathetic activation in congestive heart failure. A new therapeutic strategy.

Neurohormonal activation with increased plasma renin activity and norepinephrine and vasopressin levels is characteristic of congestive heart failure and contributes to further decompensation and poor prognosis. We treated 20 such patients with the centrally acting sympathoinhibitory drug clonidine 0.15 mg BID and obtained hemodynamic measurements by cardiac catheterization and plasma neurohormone levels before and 2 to 3 hours after the first dose; in 7 patients, these measurements were taken again after 1 week of therapy. The initial dose produced significant decreases of 8% in mean arterial pressure, 23% in right atrial pressure, 21% in pulmonary capillary wedge pressure, 19% in mean pulmonary artery pressure, and 12% in heart rate, a 17% increase in stroke volume; and no significant changes in cardiac output and systemic vascular resistance. All changes remained virtually constant after 1 week. Plasma norepinephrine decreased by 28% after the initial dose and 62% after 1 week (P < 0.1), whereas plasma renin activity remained essentially unchanged. Plasma vasopressin tended to increase, its levels being inversely correlated with those of posttreatment norepinephrine (r = -.48 P < .03). Patients with baseline norepinephrine levels > 0.400 ng/mL has significantly poorer baseline hemodynamic parameters and tended to show more improvement with clonidine, although their data remained significantly worse than patients whose baseline norepinephrine was within the normal range. Sympathetic suppression with clonidine in congestive heart failure reduces preload, heart rate, and arterial pressure, all indexes of myocardial energy demand; the lack of significant reduction in systemic vascular resistance and increase in cardiac output might be attributable in part to enhanced release of vasopressin.2+ f2p4

Percutaneous balloon pericardiotomy as a therapeutic alternative for cardiac tamponade and recurrent pericardial effusion.

A terminally ill patient with cardiac tamponade secondary to metastatic breast cancer was successfully treated by percutaneous balloon pericardiotomy. The procedure was performed through subxiphoid approach under local anaesthesia and its beneficial effect was maintained until the patient's death from her primary disease. A second, 86-year-old, debilitated patient and a third 52-year-old patient were managed likewise and both left hospital relieved from recurrent severe pericardial effusions. The later two patients have shown no signs of recurrence for fifteen and twelve months respectively.

Systolic segmental disappearance of internal mammary artery graft. Correlation with prolonged spasm of the graft.

Vasospasm of the saphenous vein and internal mammary grafts may develop spontaneously under several conditions. We present for the first time spasm of a left internal mammary artery bypass graft during coronary arteriography. A patient who underwent coronary artery bypass operation 4 years ago was recatheterized because he developed chest pain. Selective catheterization of the left internal mammary artery graft showed disappearance of its lumen at its distal part during systole, whereas the patient developed angina. These phenomena disappeared after intravenous nitroglycerin administration.

[Single coronary artery]. / Artère coronaire unique.

A single coronary artery is a rare abnormality of the coronary circulation (0.09% in the authors' experience), a fortuitous finding on coronary angiography. The authors report three new cases of this abnormality, including one with a ventricular septal defect and another with ischaemic heart disease. Exercise stress testing was positive in two patients.

Hyperinsulinaemia in syndrome X: a marker of the syndrome?

BACKGROUND: Stimulated hyperinsulinaemia is observed in some patients with syndrome X, defined as angina, positive stress test and normal coronary arteriography, and may be involved in the pathogenesis of the syndrome. An increased sympathetic response to exercise may also be pathogenetically involved. However, the diagnostic value of hyperinsulinaemia as a marker of this syndrome has not been defined. METHODS: We determined blood glucose and immunoreactive insulin during fasting, at 60 and 120 min after a glucose load of 75g in 21 patients (eight men, 13 women, 53.9 +/- 7.1 years old) with syndrome X and in 21 healthy volunteers matched to the patients for age, sex and body mass index (eight men, 13 women, 51.6 +/- 9.3 years old). Insulin values were related to the rate-pressure product increase at first exercise stage. RESULTS: The glucose values as well as the insulin values during fasting were similar in syndrome X patients and in controls. However, significantly higher insulin values (mU/l) were observed at 60 (P < 0.01) and 120 min (P < 0.005) in syndrome X patients (median 75.5 and 52, range 43-290 and 6.1-212, respectively) than in controls (median 47.5 and 24.5, range 8-195.6 and 5.2-164, respectively). A considerable overlap of insulin values, however, was observed between the two groups, with abnormal values even during fasting. For a specificity of 95%, an abnormal insulin value had a sensitivity of between 19 and 24% and a diagnostic accuracy of 57-60%. A significant positive correlation was found between insulin levels after the glucose load and the rate-pressure product increment with exercise (60 min, r = 0.60; 120 min, r = 0.65). CONCLUSION: Hyperinsulinaemia may be pathogenetically involved in syndrome X patients, in close relation to the higher sympathetic drive that characterizes this syndrome. However, the wide range of insulin values, frequently overlapping with normal values, limits the usefulness of this abnormality as a marker of the syndrome.

Intracoronary Palmaz-Schatz stent placement after complicated angioplasty: medium term follow-up.

Acute or impending coronary artery occlusion during percutaneous coronary balloon angioplasty represents a serious and potentially life-threatening complication. We studied the clinical and angiographic outcome in 21 patients who underwent emergent intracoronary Palmaz-Schatz stent implantation (11 due to persistent residual stenosis and 10 due to flow-limiting dissection) during complicated balloon angioplasty and who were followed for a mean period of 7.9 +/- 5.7 months. Excluding one patient lost to follow-up, the event-free survival rate was 70%. Six (30%) patients developed adverse clinical events. One died and 3 required elective revascularization procedures. One subacute stent thrombosis was documented. Acute Q-wave myocardial infarction occurred in 2 patients. Among 9 patients studied angiographically 5.6 +/- 2.5 months after stent placement, 2 had developed restenosis (> 50% luminal narrowing). Eleven have remained essentially symptom free. For selected patients, emergent deployment of a Palmaz-Schatz coronary stent, following complicated balloon angioplasty, offers satisfactory long-term results, thus obviating the need for a high risk emergency bypass surgery.

Effect of successful coronary angioplasty on the signal-averaged electrocardiogram.

The effect of successful coronary artery angioplasty on the signal-averaged electrocardiogram (SAECG) was examined in 50 patients (41 men, 9 women, aged 55 +/- 8 years) with stable (26 patients) or unstable angina (24 patients) and good overall left ventricular function (ejection fraction = 55% +/- 8%). The SAECG was recorded before and within 24-48 hours after the angioplasty and was filtered at 40-250 Hz, with 250 beats averaged. The noise level averaged 0.57 +/- 0.15 microV before and 0.56 +/- 0.17 microV after the procedure. There was no overall significant difference between pre- and postangioplasty SAECGs. Subgroup analysis showed that 14 patients had a significant increase of the root mean square voltage of the last 40 msec of the filtered QRS that was independent of noise level changes, previous myocardial infarction, stable or unstable angina status, positive or negative baseline SAECG, or vessel being dilated. Eleven patients (22%) had late potentials at baseline, of whom four (36%) lost them after angioplasty, while one patient developed them after the procedure, all due to root mean square voltage changes. Thus, successful angioplasty exerted no significant overall effect on the SAECG, suggesting that the substrate of late potentials was not grossly altered by the procedure in our patients. However, there appear to be some patients, constituting approximately one third of this study population, who derive a favorable influence on the SAECG from angioplasty, a subgroup that needs to be further defined in future studies.