Incremental Value of Transthoracic Doppler Echocardiography-Assessed Coronary Flow Reserve in Patients With Suspected Myocardial Ischemia Undergoing Myocardial Perfusion Scintigraphy.

BACKGROUND: Adenosine-assisted transthoracic Doppler-derived coronary flow reserve (TDE-CFR) reflects coronary vascular function. The prognostic and incremental value of left anterior descending coronary artery TDE-CFR above myocardial perfusion scintigraphy in patients with suspected myocardial ischemia has not yet been studied. METHODS AND RESULTS: Three hundred seventy-one patients (mean age, 62.3±8.7 years; 46.8% males) referred to myocardial perfusion scintigraphy attributed to suspected myocardial ischemia were included in the study. The TDE-CFR result was blinded to the referring physician. Patients were followed up regarding major cardiovascular events, defined as cardiovascular death, myocardial infarction, or acute revascularization during a median follow-up time of 4.5 years. A TDE-CFR value of ≤2.0 was considered reduced. Major cardiovascular events occurred during follow-up in 60 patients (16.2%). A reduced TDE-CFR was detected in 76 patients (20.5%). Patients with reduced TDE-CFR had an event rate of 36.8% compared to 10.8% in patients with normal TDE-CFR (unadjusted hazard ratio, 4.63; 95% CI, 2.78-7.69; P<0.001). In a multivariate model, TDE-CFR remained a significant independent predictor of major cardiovascular events. The major cardiovascular events rate was 7.5% in patients without myocardial perfusion scintigraphy-detected myocardial ischemia and normal TDE-CFR (n=200), 24.2% in patients without ischemia but with reduced TDE-CFR (n=33), and 46.5% in patients with both myocardial perfusion scintigraphy-detected myocardial ischemia and a reduced TDE-CFR (n=43; P<0.001). CONCLUSIONS: Coronary microvascular dysfunction, as determined by TDE-CFR, is a strong independent predictor of cardiovascular events and adds incremental prognostic value compared with myocardial perfusion scintigraphy. The current study supports routine assessment of CFR in patients with suspected ischemic heart disease.

Chronic total occlusions in Sweden--a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).

INTRODUCTION: Evidence for the current guidelines for the treatment of patients with chronic total occlusions (CTO) in coronary arteries is limited. In this study we identified all CTO patients registered in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and studied the prevalence, patient characteristics and treatment decisions for CTO in Sweden. METHODS AND RESULTS: Between January 2005 and January 2012, 276,931 procedures (coronary angiography or percutaneous coronary intervention) were performed in 215,836 patients registered in SCAAR. We identified all patients who had 100% luminal diameter stenosis known or assumed to be ≥ 3 months old. After exclusion of patients with previous coronary artery bypass graft (CABG) surgery or coronary occlusions due to acute coronary syndrome, we identified 16,818 CTO patients. A CTO was present in 10.9% of all coronary angiographies and in 16.0% of patients with coronary artery disease. The majority of CTO patients were treated conservatively and PCI of CTO accounted for only 5.8% of all PCI procedures. CTO patients with diabetes and multivessel disease were more likely to be referred to CABG. CONCLUSION: CTO is a common finding in Swedish patients undergoing coronary angiography but the number of CTO procedures in Sweden is low. Patients with CTO are a high-risk subgroup of patients with coronary artery disease. SCAAR has the largest register of CTO patients and therefore may be valuable for studies of clinical importance of CTO and optimal treatment for CTO patients.

Does the timing of treatment with intra-aortic balloon counterpulsation in cardiogenic shock due to ST-elevation myocardial infarction affect survival?

BACKGROUND: Intra-aortic balloon pump (IABP) counterpulsation and primary percutaneous coronary intervention (PCI) are standard treatment modalities in cardiogenic shock (CS) complicating acute myocardial infarction. The aim of this study was to investigate the impact of the timing of IABP treatment start in relation to PCI procedure. METHODS: Data were obtained from the SCAAR registry (Swedish Coronary Angiography and Angioplasty Registry) about 139 consecutive patients with CS due to ST-elevation myocardial infarction (STEMI) who received IABP treatment. The patients were hospitalized at Sahlgrenska University Hospital, Gothenburg, during 2004-2008. The cohort was divided into the two groups: group (A) in whom IABP treatment started before start of PCI (n = 72) and group (B) in whom IABP treatment started after PCI treatment (n = 67). The primary endpoint was 30-day mortality. Propensity score (PS) adjusted Cox proportional hazards regression was used to analyze predictors of 30-day mortality. RESULTS: Mean age was 66.5 ± 12 and 28% were women. All patients have received IABP treatment 30 min before or 30 min after primary PCI. 63% had diabetes and 28% had hypertension. 16% were active tobacco smokers. The mortality rate at 30 days was 38%. IABP treatment commenced before or after PCI was not an independent predictor of mortality (P = 0.72). CONCLUSION: In this non-randomized trial the treatment with insertion of IABP before primary PCI in patients with CS due to STEMI is not associated with a more favorable outcome as compared with IABP started after primary PCI.

Clinical and procedural characteristics associated with higher radiation exposure during percutaneous coronary interventions and coronary angiography.

BACKGROUND: We aim to study the clinical and procedural characteristics associated with higher radiation exposure in patients undergoing percutaneous coronary interventions (PCIs) and coronary angiography. METHODS AND RESULTS: Our present study included all coronary angiography and PCI procedures in 5 PCI centers in the Western part of Sweden, between January 1, 2008, and January 19, 2012. The radiation exposure and clinical data were collected prospectively in these 5 PCI centers in Sweden as part of the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). A prediction model was made for the radiation exposure (dose-area product) expressed in Gy·cm(2). A total of 20 669 procedures were included in the present study, consisting of 9850 PCI and 10 819 coronary angiography procedures. In multivariable analyses, body mass index (ß=1.04; confidence interval [CI], 1.04-1.04; P<0.001); history of coronary artery bypass graft surgery (ß=1.32; CI, 1.28-1.32; P<0.001); 2, 3, or 4 treated lesions (2 treated lesions: ß=1.95; CI, 1.84-2.03; P<0.001; 3 treated lesions: ß=2.34; CI, 2.16-2.53; P<0.001; and 4 treated lesions: ß=2.83; CI, 2.53-3.16; P<0.001); and chronic total occlusion lesions (ß=1.39; CI, 1.31-1.48; P<0.001) were associated with the highest radiation exposure. After adjusting for procedural complexity, radial access route was not associated with increased radiation exposure (ß=1.00; CI, 0.98-1.03; P=0.67). CONCLUSIONS: In the largest study population to assess radiation exposure, we found that high body mass index, history of coronary artery bypass graft surgery, number of treated lesions, and chronic total occlusions were associated with the highest patient radiation exposure. Radial access site was not associated with higher radiation exposure when compared with femoral approach.

Evidence for obesity paradox in patients with acute coronary syndromes: a report from the Swedish Coronary Angiography and Angioplasty Registry.

AIMS: The obesity paradox refers to the epidemiological evidence that obesity compared with normal weight is associated with counter-intuitive improved health in a variety of disease conditions. The aim of this study was to investigate the relationship between body mass index (BMI) and mortality in patients with acute coronary syndromes (ACSs). METHODS AND RESULTS: We extracted data from the Swedish Coronary Angiography and Angioplasty Registry and identified 64 436 patients who underwent coronary angiography due to ACSs. In 54 419 (84.4%) patients, a significant coronary stenosis was identified, whereas 10 017 (15.6%) patients had no significant stenosis. Patients were divided into nine different BMI categories. The patients with significant stenosis were further subdivided according to treatment received such as medical therapy, percutaneous coronary intervention (PCI), or coronary artery by-pass grafting. Mortality for the different subgroups during a maximum of 3 years was compared using Cox proportional hazards regression with the lean BMI category (21.0 to <23.5 kg/m(2)) as the reference group. Regardless of angiographic findings [significant or no significant coronary artery disease (CAD)] and treatment decision, the underweight group (BMI <18.5 kg/m(2)) had the greatest risk for mortality. Medical therapy and PCI-treated patients with modest overweight (BMI category 26.5-<28 kg/m(2)) had the lowest risk of mortality [hazard ratio (HR) 0.52; 95% CI 0.34-0.80 and HR 0.64; 95% CI 0.50-0.81, respectively]. When studying BMI as a continuous variable in patients with significant CAD, the adjusted risk for mortality decreased with increasing BMI up to ~35 kg/m(2) and then increased. In patients with significant CAD undergoing coronary artery by-pass grafting and in patients with no significant CAD, there was no difference in mortality risk in the overweight groups compared with the normal weight group. CONCLUSION: In this large and unselected group of patients with ACSs, the relation between BMI and mortality was U-shaped, with the nadir among overweight or obese patients and underweight and normal-weight patients having the highest risk. These data strengthen the concept of the obesity paradox substantially.

Stress-induced cardiomyopathy in Sweden: evidence for different ethnic predisposition and altered cardio-circulatory status.

BACKGROUND: In this paper, we report about new insights regarding clinical course, long-term outcome, ethnic/genetic predisposition and cardio-circulatory status in the large stress-induced cardiomyopathy (SIC) cohort from Sweden. METHODS AND RESULTS: We have included 115 consecutive SIC patients between January 2005 and January 2010 at Sahlgrenska University Hospital in Gothenburg. Hemodynamic status and sympathetic nerve activity were evaluated and compared with those of healthy controls. Mean age was 64, and 14% were males. Thirty-day and 3-year mortality was 6 and 10%, respectively. Eleven percent had ischemic heart disease, 3% developed thromboembolic complications, 6% had cardiac arrest and 14% developed cardiogenic shock. The great majority of SIC patients (93%) were ethnic Swedes. In three families, several close relatives developed SIC. Fourteen percent developed two or more episodes of SIC. Hemodynamic evaluation has shown subnormal systemic vascular resistance, 22% lower sympathetic activity and preserved cardiac output in SIC patients. CONCLUSIONS: SIC affects both men and women of different ages and is associated with significant short- and long-term mortality. There is a strong signal for the presence of ethnic/genetic predisposition to develop SIC. Sympathetic activity and systemic vascular resistance are lower in SIC patients, suggesting that SIC is a cardio-circulatory phenomenon.

Unfractionated heparin administration in patients treated with bivalirudin during primary percutaneous coronary intervention is associated lower mortality and target lesion thrombosis: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).

BACKGROUND: Bivalirudin reduces bleeding events and is associated with a lower mortality than the combination of unfractionated heparin (UFH) and glycoprotein IIb/IIIa inhibitor during primary percutaneous coronary intervention (PCI). However, the effect of adding UFH in patients with ST elevation myocardial infarction (STEMI) treated with bivalirudin during primary PCI is unknown. METHODS: Patients enrolled in the national Swedish Coronary Angiography and Angioplasty Registry who underwent primary PCI due to STEMI with bivalirudin as anticoagulant were evaluated. Patients were divided into two groups: those treated with bivalirudin only and those treated with bivalirudin plus a bolus dose of UFH. RESULTS: 2996 patients were included in the study: 1928 (64%) received only bivalirudin and 1068 (36%) received bivalirudin plus a bolus dose of UFH. The primary combined endpoint of death or target lesion thrombosis at 30 days occurred more often in the bivalirudin group (11.3% vs 6.5%, OR 0.55, 95% CI 0.41 to 0.72, p<0.001). This difference remained significant after adjustment (HR 0.64, 95% CI 0.44 to 0.95, p=0.03). Death at 30 days and definite target lesion thrombosis at 30 days did not differ between the two groups after adjustment (9.2% vs 5.1%, adjusted HR 0.66, 95% CI 0.42 to 1.03, p=0.07 and 2.3% vs 1.5%, adjusted HR 0.59, 95% CI 0.27 to 1.33, p=0.21, respectively). CONCLUSION: An additional bolus dose of UFH is associated with a lower rate of death or definite target lesion thrombosis at 30 days in patients undergoing primary PCI with bivalirudin as anticoagulant.

Long-term results following switch from abciximab to eptifibatide during percutaneous coronary intervention.

BACKGROUND: The usage of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors improves the outcome during high-risk percutaneous coronary interventions (PCI). The aim of this study was to evaluate the long-term effects after a planned switch from abciximab to eptifibatide during PCI. HYPOTHESIS: A switch from the general use of abciximab to eptifibatide as a GP IIb/IIIa in connection with PCI would not have any negative effects on long-term clinical outcomes. METHODS: To reduce costs, a general switch from abciximab to eptifibatide was instituted in 2004 in 2 university hospitals in Sweden. All patients treated 6 months before and 6 months after the switch were followed for 30 months. During the study period, 1038 patients underwent PCI and received a GP IIb/IIIa receptor inhibitor, 481 (46%) before the switch (Group A) and 557 (54%) after the switch (Group B). The 2 groups had similar baseline characteristics. The primary endpoint was the composite of death, myocardial infarction, stroke, or new coronary revascularization (percutaneous or surgical); secondary endpoints were the individual components of this composite. A separate analysis was performed on patients treated for ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction/unstable angina, and diabetes, respectively. Data were collected from the Swedish Coronary Angiography and Angioplasty Registry. RESULTS: There were no differences between the groups in the primary endpoint (29.7% in Group A vs 29.3% in Group B; P = 0.48) or in any of the secondary endpoints. CONCLUSIONS: A switch from the general usage of abciximab to eptifibatide as a GP IIb/IIIa receptor inhibitor in connection with PCI did not seem to have any negative effects on long-term clinical outcomes.

Levosimendan neither improves nor worsens mortality in patients with cardiogenic shock due to ST-elevation myocardial infarction.

BACKGROUND: The aim of this study was to evaluate the effect of levosimendan on mortality in cardiogenic shock (CS) after ST elevation myocardial infarction (STEMI). METHODS AND RESULTS: Data were obtained prospectively from the SCAAR (Swedish Coronary Angiography and Angioplasty Register) and the RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) about 94 consecutive patients with CS due to STEMI. Patients were classified into levosimendan-mandatory and levosimendan-contraindicated cohorts. Inotropic support with levosimendan was mandatory in all patients between January 2004 and December 2005 (n = 46). After the SURVIVE and REVIVE II studies were presented, levosimendan was considered contraindicated and was not used in consecutive patients between December 2005 and December 2006 (n = 48). The cohorts were similar with respect to pre-treatment characteristics and concomitant medications. There was no difference in the incidence of new-onset atrial fibrillation, in-hospital cardiac arrest and length of stay at the coronary care unit. There was no difference in adjusted mortality at 30 days and at one year. CONCLUSION: The use of levosimendan neither improves nor worsens mortality in patients with CS due to STEMI. Well-designed randomized clinical trials are needed to define the role of inotropic therapy in the treatment of CS.

Percutaneous coronary intervention facilitated by extracorporeal membrane oxygenation support in a patient with cardiogenic shock.

A 60-year-old man was admitted to our department with non ST-segment elevation myocardial infarction complicated by cardiogenic shock. Total revascularization, using percutaneous coronary intervention facilitated by extracorporeal membrane oxygenation support, was performed, with a favorable outcome.

Primary percutaneous coronary interventions in nonagenarians.

BACKGROUND: The optimal treatment of very elderly patients with ST elevation myocardial infarction (STEMI) is not yet defined. The aim of this study is to present the feasibility and safety of primary percutaneous coronary interventions (PCI) in nonagenarians. METHODS: A retrospective analysis of all patients who underwent primary PCI due to STEMI between 2004 and 2008 was performed. Patients age 90 years or older at the time of the procedure were identified and studied. RESULTS: Twenty-two patients fulfilled the study criteria (median age 92 years; range, 90-97 years; 50% women). The procedural success rate was 82%. Bare metal stent implantation was performed in 82% of the procedures, whereas only balloon angioplasty was performed on the rest of them. One patient experienced a minor bleeding complication. Procedural mortality was 9% (2 out of 22 patients), and it was due to "no flow" phenomenon in both patients. In-hospital mortality was 27% (6/22 patients) and 30-day mortality was 32% (7/22 patients). All 3 patients with Killip class III-IV on admission died within 30 days compared with 4 of the 19 patients with Killip class I-II (P = 0.023). Furthermore, of 11 patients with anterior infarction, 7 died within 30 days compared with none of the 11 patients with infarction of other location (P = 0.004). CONCLUSIONS: Although primary PCI is feasible in patients 90 years or older suffering from STEMI, the short-term mortality rate is high especially in patients with anterior infarct location and/or severely depressed myocardial function.

Radial vs. femoral approach for primary percutaneous coronary intervention in octogenarians.

BACKGROUND: The transradial approach is associated with fewer bleeding complications during percutaneous coronary interventions (PCIs) but is more technically challenging and associated with prolonged times during intervention. The aim of this study is to retrospectively compare the results of radial vs. femoral approach in patients >or=80 years old undergoing primary or rescue PCI. METHODS: Between January 2002 and December 2007, 354 interventions were performed in our institution with the indication of primary or rescue PCI in patients over 80 years old, without history of previous bypass operation or cardiogenic shock on presentation. Thirteen patients required a change of the approach during the procedure and were not enrolled in the final analysis. Forty (12%) interventions were performed through the transradial approach and 301 (88%) through the femoral approach. In-hospital major adverse cerebral and cardiac events and access site bleeding complications as well as 30- and 365-day mortality, procedural times, and contrast volume were evaluated. RESULTS: The two groups had similar clinical characteristics, with the exception of serum creatinine that was higher in the transfemoral approach group. There were no differences in procedural times and clinical outcomes, although the transfemoral group had numerically more access site bleeding complications (12/301 vs. 0/40, P=.41). The transradial approach had a higher conversion rate compared with the transfemoral approach (18.3% vs. 1.3%, P<.001). CONCLUSION: The transradial approach is feasible and safe in the octogenarians undergoing primary and rescue PCI, but it is associated with a high conversion rate to another approach.

Recurrent bare metal stent thrombosis: six years, single center experience.

PURPOSE: To evaluate clinical characteristics, treatment and outcomes of patients suffering from recurrent bare metal stent thrombosis (RST). METHODS: A retrospective evaluation of patients who underwent percutaneous coronary intervention (PCI) with bare metal stent implantation between January 2002 and December 2007 was performed. Patients who experienced more than one in stent thrombotic episode were identified and procedural and clinical outcomes were investigated. RESULTS: Eight thousand eight hundred sixteen patients underwent PCI with bare metal stent implantation during the study period. Ninety five patients (1.1%) underwent PCI due to stent thrombosis and 6 (6.3%) of them [mean age 69 ± 14 years (range 43-83 years)] underwent a second procedure due to RST. Emergency PCI was performed in all patients, with a favourable angiographic outcome in 4 (67%) of them. The procedure was complicated by death in 1, major ischemic stroke in 1 and acute coronary by pass grafting in 1 patient. The ejection fraction before the initial intervention and after the second thrombotic episode declined from 52 ± 14% to 33 ± 15% (p < 0.05). CONCLUSION: Recurrent stent thrombosis is a rare, but major complication following stent implantation, which dramatically affects patients' outcomes.

Switch from abciximab to eptifibatide during percutaneous coronary intervention.

BACKGROUND: Treatment with glycoprotein (GP) IIb/IIIa inhibitors during percutaneous coronary intervention (PCI) reduce ischemic complications and improve outcome. Of the GPIIb/IIIa inhibitors abciximab is better documented than eptifibatide, but the former is more expensive. The aim of this study was to monitor a switch from abciximab to eptifibatide with respect to clinical outcome up to six months after PCI. METHODS: All consecutive patients that six months before and six months after a switch from abciximab to eptifibatide received GPIIb/IIIa inhibitors during and after de novo PCIs were followed for six months with respect to clinical outcome. RESULTS: 310 patients received abciximab and 350 eptifibatide. Baseline characteristics were similar in the two groups. 55% of the patients underwent PCI for acute ST-elevation myocardial infarction and 41% for unstable coronary artery disease. There were trends for lower mortality among abciximab-treated than among the eptifibatide-treated patients during in-hospital stay (0.6% vs 2.0%:NS) as well as during the six month follow up (2.3% vs 3.7%:NS). The combined endpoint of death, myocardial infarction, stroke, repeated revascularisation and serious bleeding occurred in 14.9% in the abciximab group vs 16.8% in the eptifibatide group (NS). CONCLUSION: The study could not demonstrate any significant deterioration of clinical results after a switch from abciximab to eptifibatide as routine GPIIb/IIIa inhibition during PCI. With respect to the limited number of patients a clinical significant difference between the two GPIIb/IIIa inhibitors cannot, however, be excluded.

Silent myocardial infarction in women with type II diabetes mellitus and microalbuminuria.

INTRODUCTION: The aim of this study was to investigate whether asymptomatic women with diabetes mellitus (DM) without previous history of ischemic heart disease (IHD) and normal electrocardiogram (ECG) have suffered silent myocardial infarction (MI). METHODS: The study population consisted of 64-years old women with DM and albuminuria (n = 15) and aged- and body mass index-matched controls (n = 16). The patients were selected after screening of 240 women with previously known or unknown DM. The individuals with previous history of IHD and ECG suggesting the presence of IHD were excluded. All subjects were investigated with magnetic resonance imaging (MRI). RESULTS: MRI investigation has revealed the presence of subendocardial MI in the two DM women (13%). No MI was detected in the control group. MR coronary angiography detected the presence of significant stenosis in the proximal segment of left anterior descending (LAD) coronary artery in one DM woman. This patient developed unstable angina 1 week after the MRI investigation. The conventional angiography has confirmed the presence of significant stenosis in LAD demanding invasive revascularization by percutaneous coronary angioplasty. No difference was found in indices of left ventricular (LV) systolic function while diastolic function was disturbed in the DM group. There was a tendency for increased LV mass in the DM group. No difference was found in the LV volumes. CONCLUSION: Clinically significant proportion of the women with DM and albuminuria without previous history of IHD have had silent MI. MRI screening of these high risk female patient is valuable diagnostic tool which may increase diagnostic accuracy and improve prognosis in DM patients with IHD.

Can treatment with angiotensin-converting enzyme inhibitors in elderly patients with moderate to severe chronic heart failure be improved by a nurse-monitored structured care program? A randomized controlled trial.

OBJECTIVE: The purpose of this study was to examine whether a nurse-monitored structured care program resulted in a more effective use of angiotensin-converting enzyme (ACE) inhibitors in elderly patients compared with standard care in patients with chronic heart failure (CHF). METHODS: Hospitalized patients were screened to identify individuals with CHF, age more than 65 years, New York Heart Association classification III to IV, and no contraindications to ACE inhibitor treatment. One hundred forty-five patients were randomized to a nurse-monitored structured care program that included uptitration of enalapril to a target dose of 10 mg twice a day or to standard care. Six-month follow-up data were collected. RESULTS: The mean age of the randomized patients was 81 years. Although the proportion of patients treated with an ACE inhibitor did not differ between structured care (70%) and standard care (64%), the number of patients with the target ACE inhibitor dose was significantly higher in the structured care group (26% versus 11% in the standard care group; P <.018). Treatment had to be discontinued in 26% of the patients because of adverse effects. CONCLUSION: The patients in this study were older than in previous intervention studies and had considerable comorbidity and reduced tolerance for ACE inhibitors. ACE inhibitor treatment was underused but improved with the structured care program, although achieved treatment levels were below those in the large intervention trials in patients with CHF.