Characteristics and management of patients with acute coronary syndrome and normal or non-significant coronary artery disease: results from Acute Coronary Syndrome Israeli Survey (ACSIS) 2004-2010.

BACKGROUND: An important subset of patients presenting with acute coronary syndrome (ACS) are found to have either normal coronaries (NCs) or non-obstructive coronary artery disease (NOCAD; lumen diameter narrowing <50%). OBJECTIVES: To explore the characteristics and management strategies in this population in a real-world setting. METHODS: The Acute Coronary Syndrome Israeli Survey (ACSIS) database was utilized to compare the characteristics and therapeutic approach for patients who underwent angiography for ACS and had either NC (n = 84; 2%), NOCAD (n = 79; 2%), or obstructive coronary artery disease (OCAD; n = 3523; 96%). RESULTS: Baseline characteristics were comparable, save for a younger age and a higher proportion of females in the NC group (P<.001 for both). Prior to admission, chronic anticoagulant therapy was more frequently used in the NC vs. the OCAD group (4.8% vs. 1.6%, respectively; P=.02). Recommended ACS evidence-based medications, both in-hospital and at discharge, were less frequently prescribed to patients with NC or NOCAD. CONCLUSIONS: In a real-world practice of ACS, underutilization of evidence-based medications in patients with NC or NOCAD was observed. Nonetheless, its prognostic significance is still unknown and must be explored in larger patient cohorts.

Lack of aspirin effect: aspirin resistance or resistance to taking aspirin?

BACKGROUND: A lack of aspirin effect on platelets after a myocardial infarction (MI) is associated with poor health outcome. This lack of effect may be due to biological resistance to aspirin or due to nonadherence (the patient is not taking the aspirin, hence it has no effect). Determining which of these factors predicts poor outcome would inform potential intervention strategies. METHODS: Aspirin effect on platelets was assessed in a cohort of MI survivors who were divided into three groups: group A ("adherent"), patients whose platelets were affected by aspirin; group B ("nonadherent"), patients whose platelets showed no aspirin effect and who admitted in an interview that they were not taking their medications; and group C (potentially biologically resistant to aspirin), patients whose platelets showed no aspirin effect but maintained that they were taking their aspirin. Two health outcome measures (death, reinfarction, or rehospitalization for unstable angina; or admission for any cardiovascular causes) were assessed 12 months after enrollment. RESULTS: Seventy-three patients were enrolled and classified into groups A ("adherent," 52 patients), B ("nonadherent," 12 patients), and C ("potentially aspirin resistant," 9 patients). Adverse events and readmission were more common in the nonadherent group (B)-42% and 67%, respectively, when compared with the adherent group (A)-6% and 11%, and with the potentially biologically resistant group (C)-11% and 11%. CONCLUSIONS: Nonadherence is a significant mediator of poor outcome. It is important to evaluate whether or not patients are taking their medications in clinical settings and in studies that evaluate the effect of prescribed medications.

LINCS: L-NAME (a NO synthase inhibitor) in the treatment of refractory cardiogenic shock: a prospective randomized study.

AIMS: To evaluate the effect of L-NAME (a nitric oxide synthase inhibitor) in the treatment of refractory cardiogenic shock. METHODS AND RESULTS: We enrolled 30 consecutive patients with refractory cardiogenic shock (systolic blood pressure that deteriorated progressively to <100 mmHg during an acute coronary syndrome despite maximal percutaneous coronary revascularization, intra aortic balloon pump, and IV dopamine, furosemide and fluids treatment for at least 1h, accompanied by signs of peripheral hypoperfusion). Patients were randomized to supportive care alone (n=15, control group) or to supportive care in addition to L-NAME (1mg/Kg bolus and 1mg/Kg/h continuous IV drip for 5h n=15). Death at one month was 27% in the L-NAME group vs. 67% in the control group (p=0.008). Unaugmented mean arterial blood pressure at 24 h from randomization was 86+/-20 mmHg in the L-NAME group vs. 66+/-13 mmHg in the control group (p=0.004). Urine output increased at 24h by 135+/-78 cc/h in the L-NAME group vs a decrease of 12+/-87 cc/h in the control group (p<0.001). Time on IABP and time on mechanical ventilation were significantly shorter in the L-NAME group. CONCLUSIONS: The results of the present study further support our previous observation that NO synthase inhibitors are beneficial in the treatment of patients with refractory cardiogenic shock.

Prior peripheral arterial disease and cerebrovascular disease are independent predictors of adverse outcome in patients with acute coronary syndromes: are we doing enough? Results from the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis In Myocardial Infarction (OPUS-TIMI) 16 study.

BACKGROUND: Cerebrovascular accidents (CVAs), transient ischemic attacks (TIAs), and peripheral arterial disease (PAD) frequently coexist with coronary artery disease (CAD) and were previously reported to adversely affect the prognosis of patients with chronic CAD. METHODS: We examined the effect of prior CVA/TIA or PAD (extra-cardiac vascular disease [EVD]) on the outcome of 10,281 patients with acute coronary syndromes enrolled in the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis in Myocardial Infarction (OPUS-TIMI) 16 trial of the oral glycoprotein IIb/IIIa antagonist orbofiban plus aspirin versus aspirin alone. We evaluated mortality, recurrent cardiac events, and stroke and used multivariate analysis to control for differences in baseline characteristics. RESULTS: Patients with EVD were older, had more coronary risk factors, had a history of CAD, and received more intensive medical treatment at baseline. The acute event in these patients was more often unstable angina pectoris and less commonly Q-wave myocardial infarction. With coronary angiography, patients with prior EVD more often had multivessel disease. During the 10 months of follow-up, the presence of EVD was predictive of an increased hazard of death, reinfarction, recurrent ischemia, stroke, and a composite of these events. Despite the increased severity of the CAD and increased risk of events, patients with EVD were treated less frequently with beta-blockers and more frequently with calcium blockers. Despite patients with EVD having a 45% higher incidence of hypercholesterolemia, lipid-lowering agents were prescribed in a similar percentage of patients as patients without EVD. CONCLUSION: In patients with acute coronary syndromes, the presence of prior CVA, TIA, or PAD is associated with more extensive CAD and worse outcome. These patients appear to receive less aggressive treatment, which may explain, at least in part, their worse outcome.

RITZ-5: randomized intravenous TeZosentan (an endothelin-A/B antagonist) for the treatment of pulmonary edema: a prospective, multicenter, double-blind, placebo-controlled study.

OBJECTIVES: The objective of this study was to evaluate the addition of intravenous (IV) tezosentan to standard therapy for patients with pulmonary edema. BACKGROUND: Tezosentan is an IV nonselective endothelin (ET)-1 antagonist that yields favorable hemodynamic effects in patients with acute congestive heart failure (CHF). METHODS: Pulmonary edema was defined as acute CHF leading to respiratory failure, as evidenced by an oxygen saturation (SO(2)) <90% by pulse oxymeter despite oxygen treatment. All patients received oxygen 8 l/min through a face mask, 3 mg of IV morphine, 80 mg of furosemide, and 1 to 3 mg/h continuous drip isosorbide-dinitrate according to their blood pressure level and were randomized to receive a placebo or tezosentan (50 or 100 mg/h) for up to 24 h. RESULTS: Eighty-four patients were randomized. The primary end point, the change in SO(2) from baseline to 1 h, was 9.1 +/- 6.3% in the placebo arm versus 7.6 +/- 10% in the tezosentan group (p = NS). The incidence of death, recurrent pulmonary edema, mechanical ventilation, and myocardial infarction during the first 24 h of treatment was 19% in both groups. Reduced baseline SO(2), lower echocardiographic ejection fraction, high baseline mean arterial blood pressure (MAP), and inappropriate vasodilation (MAP reduction at 30 min of <5% or >30%) correlated with worse outcomes. A post-hoc analysis revealed that the outcome of patients who received only 50 mg/h tezosentan was better than patients in the placebo group whereas patients receiving 100 mg/h had the worst outcomes. CONCLUSIONS: In the present study, tezosentan (an ET-1 antagonist) did not affect the outcome of pulmonary edema, possibly because of the high dose used.

Coronary stent implantation without balloon predilatation: a single-center experience.

OBJECTIVE: Assessment of safety and efficacy of coronary stent deployment, without balloon predilatation. BACKGROUND: With newer high-performance balloon-premounted stents it has become more common to attempt coronary stent deployment without balloon pre- or postdilatation. METHODS: During 1998 524 coronary angioplasties were performed in the authors' institute, of which 279 resulted in coronary stenting. Of these 101 (36.2%) were stents without balloon predilatation (SWBP). PTCA was performed according to standard technique using mostly 7 F. guiding catheters, and 'rapid exchange' balloons and pre-mounted stents. RESULTS: Seventy-two patients had acute coronary syndromes (41 acute MI or post-MI angina, 28 unstable angina, 10 rescue PTCA after failed thrombolysis). Mean age was 56.4 3 11.1 years, 84.5% were males. Sixty per cent of the lesions were ACC-AHA type B2 or C. Target arteries were LAD 57.6%, LCX 21.2%, RCA 14.1% and SVG 7.1%. Procedure time was 18.2 3 17.3 minutes. Mean heparin dose was 3850 3 1570 units. Twenty-two patients received abciximab prior to stent deployment. Seven stents were not deployed without previous balloon dilatation and were retrieved safely via the guiding catheters and deployed after balloon dilatation. There was no stent embolization, ectopic suboptimal or partial stent deployment. Immediate angiographic success was obtained in 95 patients (94.1%). Minimal lumin diameter (MLD) increased from 0.27 3 0.15 to 3.23 3 2.1 mm. There were two in-hospital deaths (1.9%) due to cardiogenic shock. An intra-aortic balloon pump was required in eight patients. Two patients (1.9%) experienced subacute stent thrombosis. CONCLUSION: SWBP in selective groups of patients and lesions is feasible and safe. Larger randomized comparative trials are needed to assess the benefits and cost saving of this approach.

Periprocedural routines of coronary angioplasty--extreme diversity with unrevealed consequences.

Our objective was to evaluate the current trends of coronary angioplasty periprocedural care in the state of Israel. PTCA technology has undergone through some major developments and refinements, which have yielded new algorithms and routines. With this shift of paradigms, some of the periprocedural routines (these include medications and dosing before, during and after the procedure, as well as the handling of anti-coagulation, femoral sheath removal and the extent of patient monitoring post-PTCA) have been partially re-established. In order to assess trends in periprocedural care, we elected to analyze the current state of practice in the state of Israel. A questionnaire was sent to every cardiac catheterization laboratory in Israel that performs PTCA. An authorized senior cardiologist representing the laboratory submitted the information required for our survey. A nurse-to-nurse telephone questionnaire was conducted simultaneously to cross-examine the validity of the data. All centers submitted results. The average heparin dose for PTCA varied between 5000 and 15 000 units, ACT was monitored routinely by some and not at all by others, post-PTCA heparin administration was routinely administered by some institutions and not by others, and the mean femoral sheath dwell time ranged from 4 to 18 h. Post-PTCA cardiac monitoring varied from 6 to more than 24 h. Some institutions prescribed to all patients nitrates, calcium channel blockers and low-molecular-weight heparin, while others did not. We conclude that there is profound variability in the periprocedural routines that may translate into a significant cost increase, patient discomfort, a prolonged monitoring and hospital stay, and potential patient morbidity. We suggest that these routines should be critically evaluated, and that if they do not contribute to the procedural success and patient well-being they should be abandoned.