Ticagrelor for Secondary Prevention of Atherothrombotic Events in Patients With Multivessel Coronary Disease.

BACKGROUND: Patients with prior myocardial infarction (MI) and multivessel coronary disease (MVD) are at high risk for recurrent coronary events. OBJECTIVES: The authors investigated the efficacy and safety of ticagrelor versus placebo in patients with MVD in the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis In Myocardial Infarction 54) trial. METHODS: Patients with a history of MI 1 to 3 years before inclusion in the PEGASUS-TIMI 54 trial were stratified in a pre-specified analysis based on the presence of MVD. The effect of ticagrelor (60 mg and 90 mg) on the composite of cardiovascular death, MI, or stroke (major adverse cardiovascular events [MACE]), as well as the composite of coronary death, MI, or stent thrombosis (coronary events), and on TIMI major bleeding, intracranial hemorrhage (ICH), and fatal bleeding were evaluated over a median of 33 months. RESULTS: A total of 12,558 patients (59.4%) had MVD. In the placebo arm, compared with patients without MVD, those with MVD were at higher risk for MACE (9.37% vs. 8.57%, adjusted hazard ratio [HRadj]: 1.24; p = 0.026) and for coronary events (7.67% vs. 5.34%, HRadj: 1.49; p = 0.0005). In patients with MVD, ticagrelor reduced the risk of MACE (7.94% vs. 9.37%, HR: 0.82; p = 0.004) and coronary events (6.02% vs. 7.67%, HR: 0.76; p < 0.0001), including a 36% reduction in coronary death (HR: 0.64; 95% confidence interval: 0.48 to 0.85; p = 0.002). In this subgroup, ticagrelor increased the risk of TIMI major bleeding (2.52% vs. 1.08%, HR: 2.67; p < 0.0001), but not ICH or fatal bleeds. CONCLUSIONS: Patients with prior MI and MVD are at increased risk of MACE and coronary events, and experience substantial relative and absolute risk reductions in both outcomes with long-term ticagrelor treatment relative to those without MVD. Ticagrelor increases the risk of TIMI major bleeding, but not ICH or fatal bleeding. For patients with prior MI and MVD, ticagrelor is an effective option for long-term antiplatelet therapy. (Prevention of Cardiovascular Events [e.g., Death From Heart or Vascular Disease, Heart Attack, or Stroke] in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562).

[In favour of performing coronary balloon dilatation in 'smaller' hospitals]. / Vóór dotteren in 'kleinere' ziekenhuizen.

Until now, the permission to set up a centre for percutaneous coronary intervention (PCI) has been governed by Dutch law to ensure the availability and quality of PCI procedures. Recently, the Minister of Health proposed abolishing this law for PCI procedures. The Dutch Society of Cardiology has issued stringent guidelines for PCI centres. Even small hospitals should be able to start a PCI programme by following these stringent guidelines.

Pseudonormalisation of the T wave: old wine?: A fresh look at a 25-year-old observation.

A 74-year-old woman with documented coronary artery disease presented with symptoms of angina at rest. During these episodes of angina, the initial abnormal terminal negative T waves converted to normal positive T waves. In this article the significance of pseudonormalisation as a sign of ischaemia is reviewed. The underlying electropathological basis of this phenomenon is discussed as well. (Neth Heart J 2007;15:257-9.).

Coronary tortuosity: a long and winding road.

Coronary tortuosity is a phenomenon often encountered by cardiologists performing coronary angiography. The aetiology and clinical importance of coronary tortuosity are still unclear. Coronary tortuosity without fixed atherosclerotic stenosis in patients with angina pectoris and an abnormal exercise stress test has never been described in the literature.This article describes three cases of patients with anginal complaints, an abnormal exercise stress test and coronary angiography without the presence of a fixed atherosclerotic lesion.It is hypothesised that coronary tortuosity leads to flow alteration resulting in a reduction in coronary pressure distal to the tortuous segment of the coronary artery, subsequently leading to ischaemia. Future studies will be necessary to elucidate the actual mechanism of coronary tortuosity and its clinical significance. (Neth Heart J 2007;15:191-5.).

Posterior myocardial infarction: the dark side of the moon.

The clinical presentation of posterior myocardial infarction is not always easy, not even for the cardiologist. In this article a 70-year-old woman who presented with chest pain is described. The electrocardiogram at presentation showed marked ST-segment depression in leads V(1) to V(5) and slight ST-segment depression in leads I and aVL. There was ST-segment elevation in the posterior leads V(7) to V(9). Elevation of specific cardiac enzymes confirmed the diagnosis of myocardial infarction. True posterior myocardial infarction is difficult to recognise because the leads of the standard 12-lead electrocardiogram are not a direct representation of the area involved. Only with indirect changes in the precordial leads as such the diagnosis can be suspected. This review will highlight the electrocardiographic fine-tuned diagnosis of posterior myocardial infarction by using the posterior leads V(7) to V(9) leading to easier and faster recognition with consequences for treatment and improved prognosis. (Neth Heart J 2007;15:16-21.).

Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study.

OBJECTIVE: To assess the safety and feasibility of acute transport followed by rescue percutaneous transluminal coronary angioplasty (PTCA) or primary PTCA in patients with acute myocardial infarction initially admitted to a hospital without PTCA facilities. DESIGN: In a multicentre randomised open trial, three regimens of treatment of acute large myocardial infarction were compared for patients admitted to hospitals without angioplasty facilities: thrombolytic treatment with alteplase (75 patients), alteplase followed by transfer to the PTCA centre and (if indicated) rescue PTCA (74 patients), or transfer for primary PTCA (75 patients). RESULTS: Between 1995 and 1997 224 patients were included. Baseline characteristics were distributed evenly. Transport to the PTCA centre was without severe complications in all patients. Mean (SD) delay from onset of symptoms to randomisation was 130 (75) minutes and from randomisation to angiography 90 (25) minutes. Death or recurrent infarction within 42 days occurred in 12 patients in the thrombolysis group, in 10 patients in the rescue PTCA group, and in six patients in the primary PTCA group. These differences were not significant. CONCLUSIONS: Acute transfer for rescue PTCA or primary PTCA in patients with extensive myocardial infarction is feasible and safe. Efficacy of rescue PTCA or primary PTCA in this setting will have to be tested in larger series before this approach can be implemented as "routine treatment" for patients with extensive myocardial infarction.

Internal balloon compression: a method to achieve hemostasis when removing an inadvertently placed pacemaker lead from the subclavian artery.

One of the possible complications of subclavian vein puncture is entry into the subclavian artery. If this is not recognized, a pacemaker lead may be placed arterially. Since this may lead to systemic emboli, the pacemaker lead must be removed. This case report describes a patient in whom an atrial lead was inadvertently placed in the ascending aorta, where it had good sensing values but poor atrial capture threshold values. This lead was subsequently removed and hemostasis was achieved with intraarterial balloon compression via the brachial artery.

Resting metabolic rate in obese and normal weight women.

The relationship between resting metabolic rate and different parameters of body size was investigated among 28 female volunteers in the age group of 20--30 years. The resting metabolic rate of the subjects was determined indirectly by measuring the oxygen consumption in a closed circuit, in which the oxygen concentration was stabilised. The fat percentage of the body was determined by densitometry. The population was divided into two groups: the obese, with an average fat percentage of 33.6 and the normal-weight with an average fat percentage of 20.4. Mean values for the resting metabolic rate were 1550 kcal/24 h (6.488 MJ/24 h) for the obese and 1421 kcal/24 h (5.948 MJ/24 h) for the normal-weight group. The resting metabolic rate per kg body weight was lower in the obese than in the normal-weight persons. However, expressed per kg fat-free body mass, energy expenditure under resting conditions in the obese was higher than in the normal-weight. No single body parameter seems to be suitable in the explantation of RMR in women with substantially different fat content. The best prediction of resting metabolic rate in this population of obese and normal-weight women is obtained when both fat-free mass and fat mass are used as independent variables in a linear regression equation.