Simple bedside additive tool for prediction of in-hospital mortality after percutaneous coronary interventions.

BACKGROUND: Risk-adjustment models for percutaneous coronary intervention (PCI) mortality have been recently reported, but application in bedside prediction of prognosis for individual patients remains untested. METHODS AND RESULTS: Between July 1, 1997 and September 30, 1999, 10 796 consecutive procedures were performed in a consortium of 8 hospitals. Predictors of in-hospital mortality were identified by use of multivariate logistic regression analysis. The final model was validated by use of the bootstrap technique. Additional validation was performed on an independent data set of 5863 consecutive procedures performed between October 1, 1999, and August 30, 2000. An additive risk-prediction score was developed by rounding coefficients of the logistic regression model to the closest half-integer, and a visual bedside tool for the prediction of individual patient prognosis was developed. In this patient population, the in-hospital mortality rate was 1.6%. Multivariate regression analysis identified acute myocardial infarction, cardiogenic shock, history of cardiac arrest, renal insufficiency, low ejection fraction, peripheral vascular disease, lesion characteristics, female sex, and advanced age as independent predictors of death. The model had excellent discrimination (area under the receiver operating characteristic curve, 0.90) and was accurate for prediction of mortality among different subgroups. Near-perfect correlation existed between calculated scores and observed mortality, with higher scores associated with higher mortality. CONCLUSIONS: Accurate predictions of individual patient risk of mortality associated with PCI can be achieved with a simple bedside tool. These predictions could be used during discussions of prognosis before and after PCI.

Effect of diet on thoroughbred horses with recurrent exertional rhabdomyolysis performing a standardised exercise test.

Previous studies have associated recurrent exertional rhabdomyolysis (RER) with a diet high in soluble carbohydrate (CHO). The purpose of this study was to investigate the effect of 3 diets on clinical and metabolic parameters in 5 Thoroughbred horses with RER and 3 healthy Thoroughbreds performing a standardised exercise test (SET). Two diets were formulated to meet energy requirements for the amount of exercise being performed in the form of CHO or fat (21.4 Mcal DE/day). The third diet was formulated to provide 135% of the DE of the other 2 diets in the form of an excessive amount of carbohydrate (28.8 Mcal DE/day). Diets were fed in a crossover design for 3 week blocks and then horses performed a near maximal SET. Changes in heart rate (HR), plasma lactate, plasma glucose, total plasma solids, packed cell volume (PCV), muscle lactate and muscle glycogen concentration were measured immediately prior to, during, and 5 min after exercise. Serum creatine kinase (CK) activity was measured prior to and 4 h post SET. A 2-way ANOVA was used to examine the effect of group and dietary treatment. When dietary treatments were compared, horses fed the high-CHO diet had a mean pre-SET PCV and pre-SET HR that was higher than horses fed the fat diet (P = 0.06 and P = 0.07, respectively). Pre-SET heart rates were highest in RER horses consuming the high-CHO diet compared to RER horses consuming the low-CHO and fat diets (P = 0.02). Horses with RER had 4 h post SET CK activity greater than 400 u/l in 7/14 (50%) measurements compared to control horses which had CK activity greater than 400 u/l in 2/7 (29%) measurements. This study did not demonstrate a significant effect of diet on rhabdomyolysis, indicated by CK activity, or on the metabolic response to exercise. However, diet may have a calming effect on Thoroughbred horses with RER as manifested by decreased pre-exercise heart rates and decreased pre-exercise PCV in horses fed the fat diet.

Successful redeployment of an unexpanded coronary stent.

We report on treatment of a patient in whom failure to deploy the distal portion of a Palmaz-Schatz stent occurred but was not recognized. After an unstable course, the patient underwent repeat coronary angiography, at which time the stent was rewired and redilated. Full deployment of the stent with restoration of TIMI grade 3 flow was achieved. The putative cause of the problem, incomplete deployment of the stent because of inadvertent advancement of the stent delivery sheath, should be avoided, and needs to be recognized if it occurs. Crossing and redilating the stent is possible, although technically difficult.

Coronary embolism complicating aortic valve endocarditis: treatment with placement of an intracoronary stent.

A 37-year-old man, who had received 3 weeks of antimicrobial therapy for aortic value endocarditis, presented with an acute anteroseptal wall myocardial infarction. Coronary angiography demonstrated occlusion of the mid left anterior descending artery, thought to have been caused by embolization of a sterile vegetation. Following failure of balloon dilation to achieve vessel patency, this was achieved by placement of an intracoronary stent.

Retrospective comparative study of primary intracoronary stenting versus balloon angioplasty for acute myocardial infarction.

Balloon angioplasty has been shown to be an effective therapy for the treatment of acute myocardial infarction but is associated with a high restenosis rate, substantial early recoil, persistent thrombus and need for intracoronary thrombolysis, and a high rate of reclosure. Because many of the limitations of balloon angioplasty in the noninfarction setting are addressed by intracoronary stenting, we examined the results of primary stenting of 18 consecutive patients treated for acute myocardial infarction, and compared the results to those achieved with primary balloon angioplasty in 18 prior cases. Despite the presence of thrombus prior to angioplasty in 13 of the stented patients, no intracoronary thrombolytic therapy was required. Mean percent stenosis using quantitative coronary angiography was 17.7 +/- 10.2% after primary stenting compared with 43.7 +/- 20.3% after primary balloon angioplasty (P < .001). One stent patient who had all anticoagulant and antiplatelet therapy withdrawn early suffered subacute thrombosis. Patients were followed up to 3 yr. Complications were similar in two groups. We conclude that primary stenting for acute myocardial infarction results in superior angiographic appearance as well as resolution of thrombus without the need for routine thrombolysis, and is associated with a low complication rate and excellent short-term clinical patency.