A devices' game of thrones: cardiac resynchronization therapy vs. pacemaker.

AIMS: Oversensing can interfere with biventricular pacing. Cardiac Resynchronization Therapy (CRT) output inhibition due to automatic brady mode change from a sensing to a pacing mode of a previously implanted pacemaker as it reached battery capacity depleted indicator has not been previously published in the medical literature. METHODS AND RESULTS: We report the first case of CRT output inhibition in a pacemaker dependent patient due to electrical stimuli from a previously right-sided implanted pacemaker, after unaware reversion of OVO mode (O = no chambers paced; V = ventricular sensing; O = no response to sensing) to backup VVI (V = ventricular pacing; V = ventricular sensing; I = inhibitory response to sensing) when it reached the elective replacement interval. CONCLUSION: This paper emphasizes the importance of knowing the distinct pacemaker brady mode behaviours after battery capacity depleted indicator has been reached, according to the pacemakers' manufacturer, including the possibility of automatic brady mode change from sensing to pacing mode. It also highlights the potential for severe bradycardia or asystole of this automatic brady mode change from a previously implanted pacemaker in pacemaker dependent patients submitted to CRT upgrade.

[Streptococcus agalactiae endocarditis]. / Endocardite a Streptococcus agalactiae.

Streptococcus agalactiae endocarditis is a rare clinical entity that is generally characterized by acute onset, the presence of large vegetations, rapid valvular destruction and frequent complications, particularly embolization. Mortality is high with medical therapy alone. The authors present a case report of Streptococcus agalactiae endocarditis in a young patient treated by prompt surgery. The literature is reviewed.

[Coronary artery anomalies]. / Anomalias das artérias coronárias.

Coronary artery anomalies (CAAs) are a rare entity but their true incidence in the general population has yet to be determined. Most CAAs are asymptomatic, but they are nevertheless the second leading cause of sudden death in apparently healthy young athletes. The new imaging methods available to cardiologists, including CT angiography and MRI, now enable noninvasive diagnosis and characterization of these anomalies. The authors review the literature and present a retrospective study of 360 consecutive patients who underwent cardiac CT angiography. Demographic, clinical and angiographic characteristics were studied. The incidence of CAAs in this population was 2.69%. In order to better characterize this disorder, including diagnostic strategy, screening, treatment and prognosis, the authors suggest the establishment of a national registry of cardiac CT angiography. Such a registry would fill the existing gap in information on exams performed in the country, enriching current knowledge about this disease and noninvasive cardiac imaging in Portugal.

Relationship between coronary disease and subclinical hypothyroidism: an angiographic study.

INTRODUCTION: The definition of subclinical hypothyroidism (SH) is an asymptomatic state in which free thyroxine (T4) is normal and thyroid-stimulating hormone (TSH) levels are elevated. Its relationship with coronary disease is not clear and has been the subject of recent interest. Current evidence is conflicting and there is a lack of studies supported by coronary angiography. OBJECTIVE: To assess the relationship between SH and the presence and extent of coronary disease diagnosed by angiography. METHODS: We prospectively studied 354 consecutive patients referred for elective coronary angiography. Those with known thyroid disease, documented coronary disease or previous myocardial infarction were excluded. Fasting blood specimens were collected to measure thyroid hormones, lipid profile, high-sensitivity C-reactive protein, fibrinogen and NT-proBNP. Patients with SH were compared with those without to assess differences in clinical characteristics and biochemical and angiographic results. Significant coronary disease was defined as the presence of at least one lesion with > or = 50% luminal stenosis. Lesions with <50% stenosis were considered minimal. RESULTS: SH was diagnosed in 32 (9%) patients. Mean age was similar between the groups. There were more women (66% vs. 39%; p=0.003) and atrial fibrillation was more frequent (25% vs. 11%; p=0.016) in the group of patients with SH. There were no significant differences in the other baseline clinical parameters, and blood biochemistry results were similar in the two groups, with the exception of higher levels of NT-proBNP in SH patients, although without statistical significance. The angiographic results were as follows: significant coronary disease (SH 28.1% vs. non-SH 43.8%; p=0.087); three-vessel disease (9.4% vs. 9.9%; p=0.919); two-vessel disease (12.5% vs. 13.4%; p=0.892); single-vessel disease (6.3% vs. 29.5%; p=0.051); minimal lesions (9.4% vs. 10.9%; p=0.794); and no coronary disease (62.4% vs, 45.3%; p=0.064). CONCLUSION: In this population SH was not associated with the presence or extent of coronary disease diagnosed by coronary angiography.

Use of nitroglycerin in the active phase of tilt testing: is there a difference in elderly patients?

INTRODUCTION: The importance of tilt testing has been demonstrated in the evaluation of patients with syncope of unknown cause, and it is the gold standard technique for the diagnosis of neurocardiogenic syncope, particularly with the use of pharmacological provocative agents to improve diagnostic accuracy. Stimulation with sublingual nitroglycerin is generally well tolerated and increases test sensitivity, shortening the test duration; this also allows the test to be applied in elderly patients. OBJECTIVES: To evaluate, in a population referred for syncope of unknown etiology, the value of tilt testing with sublingual nitroglycerin and to compare the responses obtained in elderly and younger patients. METHODS: We studied 158 patients who underwent tilt testing using nitroglycerin as a provocative agent. We compared patients aged <65 years (Group A, n=74) and > or =65 years (Group B, n=84). Tilt testing was performed according to the Italian protocol, with continuous monitoring of the electrocardiogram and blood pressure (Task Force Monitor, CNSystems). Only patients who were asymptomatic in the passive phase of the test were included. The test was considered positive for neurocardiogenic response when symptoms were reproduced with bradycardia and/or hypotension; the responses were classified as cardioinhibitory, vasodepressor or mixed. A gradual and parallel decrease in blood pressure after nitroglycerin administration, followed by syncope, was considered an exaggerated response to nitrates. RESULTS: There were no differences in gender distribution between groups. Tilt testing was positive in 57% of group A and 51% of group B patients (p=NS), with an exaggerated response to nitrates in 11% and 16% respectively (p=NS). With regard to neurocardiogenic responses, vasodepression was more frequent in group B (53% vs. 24%; p=0.001), while a mixed response tended to be more frequent in group A (59% vs. 40%; p=0.07), with no significant difference in cardioinhibitory responses (17% in group A vs. 7% in group B; p=NS). CONCLUSIONS: In a population with syncope of unknown origin, tilt testing potentiated with nitroglycerin: a) makes a significant contribution to clarifying diagnosis and is of equal value in both elderly and younger patients; and b) is associated with a higher incidence of neurocardiogenic vasodepressor response in the elderly, although with a similar rate of exaggerated responses to nitrates.

Temporal variations in microvolt T-wave alternans testing after acute myocardial infarction.

BACKGROUND: Microvolt T-wave alternans (TWA) have been accepted as a tool for assessing vulnerability to ventricular tachyarrhythmias. There is lack of data concerning prospective temporal variations in TWA measurements after acute myocardial infarction (AMI). We analysed the temporal patterns of TWA in post-AMI patients. METHODS AND RESULTS: TWA tests were performed <1 month (TWA_early) and 6 months (TWA_late) after AMI in 51 consecutive patients treated with successful percutaneous coronary intervention (PCI). Twenty seven patients (53%) had anterior wall infarctions and 24 (47%) had inferior/lateral wall infarctions. TWA was measured during a treadmill manual exercise protocol and defined as positive, negative and indeterminate. Group A included patients with TWA negative in both tests and Group B included those with TWA abnormal (positive or indeterminate) at first or second determinations. TWA_early was negative, positive and indeterminate in 38 (74.6%), 8 (15.6%) and 5 (9.8%) patients, respectively, whereas TWA_late was negative, positive and indeterminate in 30 (58.9%), 14 (27.4%) and 7 (13.7%) patients, respectively. TWA_early was classified as normal in 74.6% and abnormal in 25.4% of the cases, and TWA_late was normal in 58.9% and abnormal in 41.1%. TWA tests were concordant in 36 patients (70.6%) and discordant 15 patients (29.4%). At TWA_late, 10 patients (19.6%) changed from TWA negative to TWA abnormal and 4 patients (7.8%) from TWA abnormal to TWA negative. After TWA_early+TWA_late, 45% of the patients had 1 test classified as abnormal. Left ventricular ejection fraction was <50% in 22% of Group A and 52% of Group B (P = 0.037). CONCLUSIONS: In the era of primary PCI, temporal changes in TWA measurements may occur frequently during the first 6 months post-AMI. These findings should be considered in risk stratification strategies following AMI.

Assessment of T-wave alternans after acute myocardial infarction: influence of the timing of PTCA on cardiac electrical stabilization.

UNLABELLED: It is accepted that the timing of myocardial revascularization in patients undergoing PTCA for the treatment of acute myocardial infarction (AMI) may improve the clinical outcome. However, its impact on microvolt T-wave alternans (TWA), a recognized tool for assessing vulnerability to ventricular tachyarrhythmias that can cause sudden cardiac death in infarction survivors, remains unknown. AIM: To analyze TWA in patients with AMI treated by PTCA and assess whether the timing of myocardial revascularization can influence TWA measurements. METHODS: We studied 79 patients (67 male; 57 +/- 11 years) who underwent successful PTCA for the treatment of AMI. The presence of TWA was assessed using a HearTwave system (Cambridge Heart, Inc.) within 30 days of AMI. Orthogonal Frank XYZ leads and associated vector magnitude (microvolt alternans sensors) and 7 standard ECG leads were recorded during a treadmill manual exercise protocol to increase heart rate slowly to approximately 110 bpm. TWA was considered positive if the sustained alternans microvoltage was > or = 1.9 microV at heart rates of > 100 bpm, negative if the criteria for positivity were not met while maintaining heart rate at > or =105 bpm (maximum negative heart rate), and inconclusive if it could not be definitively classified as either positive or negative. Patients were excluded if they had atrial fibrillation, > 10 extrasystoles/min, bradycardia 40 beats/min, wide QRS complex, congestive heart failure or implanted pacemaker, or were under antiarrhythmic therapy. The presence of positive or inconclusive TWA (non-negative TWA) was considered a risk marker for the occurrence of life-threatening ventricular arrhythmias. TWA results were compared between the group of patients who underwent PTCA within 24h of AMI (early PTCA; n=45) and those treated >24h after hospital admission (late PTCA; n=34). RESULTS: TWA was positive in 16 patients (20.2%), negative in 56 (70.9%) and inconclusive in 7 (8.9%). Overall, TWA was non-negative in 29.1% of the patients. In the early PTCA group, TWA was non-negative in 9 patients (20%) (6 positive and 3 inconclusive) and negative in 36 (80%). In the late PTCA group, TWA was non-negative in 14 patients (41%) (10 positive and 4 inconclusive) and negative in 20 (59%) (p < 0.05). There were no differences in left ventricular ejection fraction between the two groups. No spontaneous ventricular arrhythmias, syncope or deaths were recorded in the first 60 days after hospital discharge. Five patients (7%) were re-admitted with angina. CONCLUSIONS: In a population of AMI survivors: a) the prevalence of non-negative TWA was 25%, despite myocardial revascularization by PTCA; b) PTCA performed within 24h of onset of AMI significantly reduced the number of patients with non-negative TWA, suggesting a lower arrhythmic risk. These findings should be investigated in larger studies.

Rupture of a congenital aneurysm of the non-coronary sinus of Valsalva into the right atrium.

We present the case of a patient evaluated for a continuous murmur, in which a ruptured congenital sinus of Valsalva aneurysm with fistulization to the right atrium was demonstrated by echocardiography. The authors review the relevant clinical features of this entity.

Infective endocarditis complicated by large aortic pseudoaneurysm after cardiac surgery.

A 66-year-old female with Streptococcus viridans aortic and tricuspid infective endocarditis develops, during the course of antibiotic therapy, rupture of a right coronary sinus of Valsalva aneurysm to the right ventricle. An urgent cardiac surgery is preformed with implantation of a mechanical aortic prosthesis and a right coronary sinus plasty. Six months later a huge aortic pseudoaneurysm is diagnosed and she is submitted to a second uneventful surgery. A review is done for the significant features with discussion of diagnosis and therapy.

Impact of combination medical therapy on mortality in patients with acute coronary syndromes.

INTRODUCTION: Conventional risk stratification after acute myocardial infarction is usually based on the extent of myocardial damage and its clinical consequences. However, nowadays, more aggressive therapeutic strategies are used, both pharmacological and invasive, with the aim of changing the course of the disease. OBJECTIVES: To evaluate whether the number of drugs administered can influence survival of these patients, based on recent clinical trials that demonstrated the benefit of each drug for survival after acute coronary events. METHODS: This was a retrospective analysis of 368 consecutive patients admitted to our ICU during 2002 for acute coronary syndrome. A score from 1 to 4 was attributed to each patient according to the number of secondary prevention drugs administered--antiplatelets, beta blockers, angiotensin-converting enzyme inhibitors and statins--independently of the type of association. We evaluated mortality at 30-day follow-up. RESULTS: Mean age was 65 +/- 13 years, 68% were male, and 43% had ST-segment elevation acute myocardial infarction. Thirty-day mortality for score 1 to 4 was 36.8%, 15.6%, 7.8% and 2.5% respectively (p < 0.001). The use of only one or two drugs resulted in a significant increase in the risk of death at 30 days (OR 4.10, 95% CI 1.69-9.93, p = 0.002), when corrected for other variables. There was a 77% risk reduction associated with the use of three or four vs. one or two drugs. The other independent predictors of death were diabetes, Killip class on admission and renal insufficiency. CONCLUSIONS: The use of a greater number of secondary prevention drugs in patients with acute coronary syndromes was associated with improved survival. A score of 4 was a powerful predictor of mortality at 30-day follow-up.

The prognostic impact of renal failure in patients with ST-segment elevation acute myocardial infarction.

INTRODUCTION: Renal insufficiency (RI) is associated with higher morbidity and mortality in patients (P) with coronary artery disease and in P submitted to angioplasty. In ST-segment elevation acute myocardial infarction (STEAMI), this impact has not been well demonstrated. AIM: To evaluate the impact of RI in P with STEAMI. METHODS: We evaluated 160 P admitted with STEAMI, mean age of 62+/-14 years, 76% male. We determined creatinine levels on admission. RI was defined as a level >1.5 mg/dl. Analysis of clinical, electrocardiographic and laboratory variables was performed, in relation to the endpoint defined as the occurrence of death at 30-day follow-up. RESULTS: There were 16 deaths (10%) at 30-day follow-up. P with RI (n=21) were older (68+/-11 vs 61+/-14 years, p<0.001), more often had diabetes (57 vs 24 %, p=0.004) and presented more often with Killip class > or =2 (57 vs 12%, p<0.001). The use of statins (62 vs 83%, p=0.05) and beta-blockers (24 vs 65%, p<0.001) was lower in P with RI. Mortality was higher in RI P (62 vs 2%, p<0.001). The univariate predictors of death were age > or =75 years, diabetes, Killip class > or =2 on admission, RI, non-use of statins and beta-blockers and use of diuretics. In multivariate analysis, independent predictors of death at 30 days were RI (HR 29.6, 95% CI 6.3-139.9, p<0.001) and non-use of beta-blockers (HR 0.13, 95% CI 0.02-1.01, p=0.01). CONCLUSION: In P admitted for STEAMI, the presence of RI was an independent predictor of death at 30 days whereas the usage of beta-blockers was protective.

Thromboembolic and/or bleeding complications in patients under oral anticoagulation followed at a tertiary hospital.

UNLABELLED: A better understanding of the characteristics of patients that come to the anticoagulation (AC) clinic of a tertiary hospital could lead to better healthcare provision and reduce the number of thromboembolic and bleeding complications. OBJECTIVES: To evaluate the characteristics of patients followed at our AC clinic and to determine which factors could predict an increased risk of complications. METHODS: Data obtained by doctors through a questionnaire from patients attending the AC clinic of our hospital were analyzed. Demographic characteristics (gender, age, literacy, educational level), classical coronary artery disease (CAD) risk factors, the diagnosis that led to oral anticoagulation therapy (OAT) and its duration, the number of INR determinations, the minimum, maximum and current INR value and complications of OAT were studied. Complications were defined as bleeding and/or thromboembolic events occurring during the course of OAT. RESULTS: Of the 101 patients enrolled, 74 were female (73.3%), with a mean age of 6410 years (21-85). This population had had 4.53.5 years of schooling and there was a 15% incidence of illiteracy. The main reason for OAT was mechanical valve prosthesis implantation (56.4%). Each patient had an average of one CAD risk factor. The mean number of months of OAT was 99.489 (1-360). Sixty-six patients (65.3%) knew the reason for the therapy. Each patient had 1.20.6 INR determinations per month. Forty-five patients had bleeding and/or thromboembolic complications during OAT. There were 50 bleeding complications in 41 patients, seven leading to hospital admission. There were 7 thromboembolic events (central or peripheral), in 7 patients. The patients were divided into two groups: group I--with complications (GI) and group II--without complications (GII). There were 45 patients in GI, mean age 63.59.1 years (39-80), and 56 patients in GII, mean age 64.711.3 years (21-85). A greater number of complications were found in patients with mitral valve mechanical prostheses (GI--60.6%; GII--9.4%; p = 0.024). More complications were also found in patients with recommended maximum INR >3 (GI--55.2; GII--44.8; p = 0.013) and in those who had undergone dental procedures (GI--68.3%; GII--31.7; p < 0.001). The duration of OAT had the greatest predictive value for the development of complications (GI--138.196.5 months; GII--67.868.2 months; p < 0.00005). Multivariate analysis identified OAT duration as the only independent predictive factor. CONCLUSIONS: The high percentage of illiteracy found in this observational study could have hindered understanding of this sometim&e complex therapy. However, in our study this was not a significant predictor of complications. The predictive factors for bleeding and/or thromboembolic complications during OAT were the duration of therapy, the recommended maximum INR value and dental procedures. After multivariate analysis only the first variable was shown to be significant in this context.

Multivalve endocarditis with multiple peripheral and pulmonary embolisms: a case report.

Fever of unknown origin in elderly patients is a difficult diagnostic problem. Infective endocarditis is often not diagnosed in this group of patients, in whom other etiologies like cancer are considered first. The authors report a case in which an elderly woman with subacute mitral and tricuspid infective endocarditis was correctly diagnosed only after a peripheral embolism. Besides having multiple pulmonary and peripheral embolisms, she developed a left femoral mycotic aneurysm.

[Large pseudoaneurysm of left ventricle following cardiac surgery]. / Volumoso pseudoaneurisma do ventrículo esquerdo após cirurgia cardíaca.

A 75-year old female patient, with previous inferior acute myocardial infarction (AMI) in December 2000, was admitted in April 2001 with angina and heart failure. Transthoracic echocardiography (TTE) was suggestive of a postero-inferior pseudoaneurysm (PA) of the left ventricle (LV), with 61x49 mm. of size and mitral regurgitation. Cardiac catheterization was suspected of a PA of the LV and revealed a three vessels coronary artery disease. On 20th April she was submitted to cardiac surgery with resection of a large LV aneurysm (AN) and triple coronary artery bypass surgery. Afterwards, she was on NYHA class III and subsequent TTE and transesophagic echocardiography (TEE) were suggestive of a 90x60 mm LV posterior PA (confirmed by nuclear magnetic resonance) and severe mitral regurgitation, with good LV systolic function. She underwent a new cardiac surgery on 31st May 2002, with resuturing of the LV postero-inferior wall patch and removal of the PA. The patient is in good condition and on NYHA functional class I-II.

Long-term clinical outcome in patients with severe left ventricular dysfunction and an implantable cardioverter-defibrillator after ventricular tachyarrhythmias.

UNLABELLED: Left ventricular ejection fraction (LVEF) is accepted as an important prognostic marker in patients (pts) with implantable cardioverter-defibrillators (ICD). The impact of this therapeutic approach in the survival of pts with life-threatening arrhythmias and severe left ventricular dysfunction remains a matter of discussion. OBJECTIVE: To evaluate the long-term clinical implications of severe left ventricular dysfunction in pts with an ICD implanted for secondary prevention of sudden cardiac death (SD). METHODS: Out of 70 pts undergoing ICD implantation in our institution over four consecutive years, we studied 24 pts with LVEF <35% and a post-ICD follow-up of >12 months (87.5% male; age 62.79 years). The index arrhythmia was ventricular tachycardia in 19 cases and SD with ventricular fibrillation in 5 cases. The underlying disease was ischemic cardiomyopathy (n=19), dilated cardiomyopathy (n=4) and hypertensive heart disease (n=1). Mean LVEF at the time of implant was 25 +/- 7% (between 11% and 34%; NYHA class II/III in 83.3%). A du chamber system was implanted in 5 cases, and an ICD plus cardiac resynchronization pacing in 2 cases. There was no perioperative mortality. At the time of discharge, 71.2% of the pts were taking amiodarone and 66.7 % beta-blockers. During a 38 +/- 16-month follow-up (4 appointments/year), we analyzed the following parameters: rehospitalization for cardiovascular cause, appropriate ICD shocks, inappropriate detections/therapy, nonfatal major arrhythmic events (arrhythmic storm, therapeutic exhaustion, recurrent ventricular tachycardia), cardiac mortality, SD and total mortality. RESULTS: Forty-five readmissions (1.9 +/- 2.3/pt) occurred in 14 pts (58%), 24.4% due to congestive heart failure. Appropriate ICD shocks (without hospitalization) occurred in 62.5% of the pts, 16.6% had inappropriate therapy (50% because of increased heart rate due to atrial fibrillation) and 37.5% suffered nonfatal major arrhythmic events. Death due to SD was 4.2%, cardiac mortality 12.5% and total mortality 25%. CONCLUSIONS: Severe left ventricular dysfunction is common in ICD pts. During long-term follow-up, the majority of these pts receive appropriate ICD shocks, which emphasizes the importance of SD prevention in this population. The frequent documentation of supraventricular arrhythmias (causing inappropriate ICD therapy) and nonfatal major arrhythmic events also reflects the presence of a worse arrhythmic substrate in this subgroup. Despite the poor initial prognosis associated with ventricular tachyarrhythmias in pts with severe left ventricular dysfunction, ICD therapy may contribute to a better long-term clinical outcome.

Selective pulmonary vasodilators for severe pulmonary hypertension: comparison between endpoints.

UNLABELLED: The therapeutic approach to severe pulmonary arterial hypertension (PAH), whether primary or secondary to connective tissue disorders, thromboembolic phenomena or congenital heart disease with Eisenmenger syndrome, has evolved in recent years following the introduction of selective pulmonary vasodilators, including prostacyclin analogs and endothelin receptor antagonists. AIM: To correlate three different endpoints (6-minute walk test, Tei index and peak tricuspid regurgitation velocity by Doppler echocardiographic study) during follow-up of PAH patients under selective vasodilator therapy. METHODS: Eleven patients (9 female, age 42 +/- 18 years) with severe PAH (> or = 65 mmHg), 64% with Eisenmenger syndrome, in NYHA class > or = II, were assessed during a follow-up of 11 +/- 8 months. Eight patients were already under therapy with iloprost or bosentan. RESULTS: There was no correlation between the three endpoints before and after therapy as assessed by Pearson's correlation coefficient. There was, however, an improvement in all of them after selective vasodilatory therapy. CONCLUSION: Therapeutic response can be accurately measured by the traditional endpoint (6-minute walk test) or by echocardiographic endpoints. However, the lack of correlation between them excludes their use as alternatives in patient follow-up.

Differences in outcome in primary angioplasty in women.

BACKGROUND: In acute myocardial infarction (AMI), primary percutaneous transluminal coronary angioplasty (PTCA) has proved to be the best therapeutic approach. Several factors have been associated with worse outcome in AMI in females. Are there differences in outcome in women undergoing PTCA for AMI? AIM: To evaluate gender influence on clinical outcome and in-hospital mortality in patients with AMI who undergo primary percutaneous interventions. METHODS: We studied 245 consecutive patients (72 women, 29.4 %), who underwent primary PTCA between January 2000 and December 2001. The following parameters were analyzed: risk factors for coronary artery disease including hypertension, diabetes, smoking, hypercholesterolemia and family history, previous AMI, PTCA or angina, pain-to-balloon time, extent of coronary disease and outcome. RESULTS: Female patients were older (67.9+/-11.6 vs. 59.6+/-13; p < 0.001) with a higher prevalence of hypertension (65.3 % vs. 47.4 %; p < 0.05) and angina (29.0 % vs. 16.0 %; p < 0.05) and lower prevalence of smoking (27.8 % vs. 54.3 %; p < 0.001). Pain-to-balloon time was longer in women (6.8+/-4.1 vs. 5.4+/-3.7 hours; p < 0.05). Extent of coronary disease was similar in both groups. Glycoprotein IIb/IIIa inhibitors were used in 84.7 % of women and 90.8 % of men. The frequency of hemorrhagic complications (5.6 % vs. 5.2 %) and arrhythmias (15.3 % vs. 10.4%) and in-hospital mortality (9.7 6.4 %) were higher in females, although without statistical significance (p = NS). Hospitalization time was similar in both groups. CONCLUSIONS: Despite the growing awareness of a gender bias in therapeutic approaches to AMI, there are still some differences in outcome, with a trend towards higher mortality rates in women. Older age and longer pain-to-balloon time could account for this.

Primary coronary angioplasty in the elderly.

BACKGROUND: Primary coronary angioplasty is the best therapeutic approach in acute myocardial infarction (AMI), and more so in the population aged over 75 years, in whom the hemorrhagic risk of thrombolysis becomes almost unacceptable. AIM: To evaluate age-related influences on clinical evolution and in-hospital mortality in patients with AMI who undergo primary percutaneous coronary interventions (PCI). METHODS: We studied 245 consecutive patients (aged between 31 and 90, 63+/-13), who underwent primary PCI between January 2000 and December 2001. Forty-six patients (18.8%) aged over 75 years were compared with the rest. The following parameters were analyzed: risk factors for coronary artery disease including hypertension, diabetes, smoking, hypercholesterolemia and family history, previous AMI, PCI or angina, extent of coronary disease, angiographic results and in-hospital mortality. RESULTS: Female gender was more frequent in older patients (56.5% vs. 23.1%; p<0.001) and smoking was more prevalent in the younger group (54.3% vs. 13.0%; p<0.001), as was previous AMI (p<0.05). PCI success was high in both groups (93.5% in the older population and 96.7% in the rest; p=NS), multivessel coronary disease was significantly more frequent in the elderly group (41.3% vs. 26.2%; p<0.05), and glycoprotein IIb/IIIa inhibitors were used less (80.4% vs. 91%; p<0.05). Killip class evolution was more favorable in the younger group (class I in 88.4% vs. 69.8% in older patients; p<0.001). The number of hemorrhagic complications and in-hospital mortality were higher in elderly patients (3.5% vs. 13.0%; p<0.05 and 4.5% vs. 19.6%; p<0.001, respectively). CONCLUSIONS: Primary PCI has a similarly high success rate in elderly patients, although this age-group still has higher mortality. The increased rate of hemorrhagic complications in this population should lead to greater caution in the use of adjuvant antithrombotic drugs.