BACKGROUND: A substantial proportion of patients receiving fibrinolytic therapy for myocardial infarction with ST-segment elevation have inadequate reperfusion or reocclusion of the infarct-related artery, leading to an increased risk of complications and death. METHODS: We enrolled 3491 patients, 18 to 75 years of age, who presented within 12 hours after the onset of an ST-elevation myocardial infarction and randomly assigned them to receive clopidogrel(300-mg loading dose, followed by 75 mg once daily) or placebo. Patients received a fibrinolytic agent, aspirin, and when appropriate, heparin(dispensed according to body weight) and were scheduled to undergo angiography 48 to 192 hours after the start of study medication. The primary efficacy end point was a composite of an occluded infarct-related artery(defined by a Thrombolysis in Myocardial Infarction flow grade of 0 or 1) on angiography or death or recurrent myocardial infarction before angiography. RESULTS: The rates of the primary efficacy end point were 21.7 percent in the placebo group and 15.0 percent in the clopidogrel group, representing an absolute reduction of 6.7 percentage points in the rate and a 36 percent reduction in the odds of the end point with clopidogrel therapy(95 percent confidence interval, 24 to 47 percent; P 0.001). By 30 days, clopidogrel therapy reduced the odds of the composite end point of death from cardiovascular causes, recurrent myocardial infarction, or recurrent ischemia leading to the need for urgent revascularization by 20 percent(from 14.1 to 11.6 percent, P=0.03). The rates of major bleeding and intracranial hemorrhage were similar in the two groups. CONCLUSIONS: In patients 75 years of age or younger who have myocardial infarction with ST-segment elevation and who receive aspirin and a standard fibrinolytic regimen, the addition of clopidogrel improves the patency rate of the infarct-related artery and reduces ischemic complications.

Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation

CONTEXT\nAccurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy.\n\n\nOBJECTIVE\nTo develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS.\n\n\nDESIGN, SETTING, AND PATIENTS\nA multinational registry, involving 94 hospitals in 14 countries, that used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months postdischarge. From 17,142 patients presenting with an ACS from April 1, 1999, to March 31, 2002, and discharged alive, 15,007 (87.5%) had complete 6-month follow-up and represented the development cohort for a model that was subsequently tested on a validation cohort of 7638 patients admitted from April 1, 2002, to December 31, 2003.\n\n\nMAIN OUTCOME MEASURE\nAll-cause mortality during 6 months postdischarge after admission for an ACS.\n\n\nRESULTS\nThe 6-month mortality rates were similar in the development (n = 717; 4.8%) and validation cohorts (n = 331; 4.7%). The risk-prediction tool for all forms of ACS identified 9 variables predictive of 6-month mortality: older age, history of myocardial infarction, history of heart failure, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting electrocardiogram, and not having a percutaneous coronary intervention performed in hospital. The c statistics for the development and validation cohorts were 0.81 and 0.75, respectively.\n\n\nCONCLUSIONS\nThe GRACE 6-month postdischarge prediction model is a simple, robust tool for predicting mortality in patients with ACS. Clinicians may find it simple to use and applicable to clinical practice.

A validated prediction model for all forms of acute coronary syndrome: Estimating the risk of 6-month postdischarge death in an international registry

This study was undertaken to assess the value of sublingual nitroglycerin administration during u as a simple practical test for the diagnosis o P right tilt vasovagal syncope. To this purpose, 235 patients with syncope of unknown origin and no evidence of organic heart disease (110 men, mean age 52 f 20 years) and 35 asymptomatic control subjects underwent head-up tilt testing with nitroglycerin challenge. Patients and subjects were tilted at 60” for 45 + 20 minutes; the initial 45 minutes were without medication and the final 20 minutes after 300 pg of sublingual nitroglycerin. During the drug-free phase of the test, 59 patients (25%) and no controls had a positive response. After drug administration, a positive response (syncope in associa-

Value of Head-Up Tilt Testing Potentiated With Sublingual Nitro lycerm to Assess the Origin of Unexp ained 1 Syncope

Coronary intervention for persistent occlusion after myocardial infarction.

Review Form First Author, Year: ___________________ Ref ID #__________ Abstractor Initials: ___ ___ ___ Primary Inclusion/Exclusion Criteria 1. Relevant to SER topic Yes No Cannot Determine 2. Attempts internal or external validation Yes No Cannot Determine 3. Published in English Yes No Cannot Determine 4. Original research (exclude reviews, editorials, commentaries, letters to editor, etc.) Yes No Cannot Determine 5. Eligible Study types a. Randomized controlled trials b. Controlled clinical trials

Systematic Review of Cardiovascular Disease Risk Assessment Tools

In this paper, we present a case of a female patient with clinically unstable angina pectoris and a bordeline stenosis in the proximal segment of the left anterior descending coronary artery as assessed by coronary angiography and intravascular ultrasound. Virtual histology revealed morphological criteria of a vulnerable plaque forming the culprit lesion. Optical coherence tomography visualized both fibrous cap fracture and a significant stenosis of a coronary artery caused by soft structures identified as mural thrombus covering the plaque surface. The image of atherosclerotic plaque obtained by optical coherence tomography enabled explanation of the cause of coronary instability and influenced subsequent management. The presented case illustrates usefulness of optical coherence tomography as an imaging method complementary to virtual histology and intravascular ultrasound in the diagnostic evaluation of selected patients with acute coronary syndromes. Application of optical coherence tomography in the assessment of vulnerable atherosclerotic plaques is discussed as related to the presented case. (Cardiol J 2008; 15: 561–566)

/pdf/usefulness-of-optical-coherence-tomography-in-the-assessment-40ohcn1o13.pdf

Usefulness of optical coherence tomography in the assessment of atherosclerotic culprit lesions in acute coronary syndromes. Comparison with intravascular ultrasound and virtual histology.

Background: The purpose of this study was to compare risk predicted using available risk scores and actual outcomes in patients with left main coronary artery disease undergoing percutaneous coronary intervention with stent implantation (PCI LM). Methods: We studied 204 patients treated with elective or emergent coronary angioplasty. We estimated in-hospital mortality using the EuroSCORE, Parsonnet and GRACE risk scores and compared this data with actual in-hospital mortality. Results: There were no deaths among 62 patients undergoing elective PCI LM regardless of the estimated risk. Acute coronary syndrome (ACS) was diagnosed in all 142 patients undergoing emergent PCI LM. Mortality in this group was 24% (34/142). Area under receiver operating characteristic curve (AUC) values for the EuroSCORE, Parsonnet and GRACE risk scores in patients with ACS were 0.812 (p = 0.0001), 0.857 (p = 0.0001), and 0.870 (p = 0.0001), respectively. No statistically significant differences were found when these AUC values for different evaluated risk scores were compared. Overall, the EuroSCORE and Parsonnet risk scores had no discriminative value, as all deaths occurred in the highest risk group. Only the GRACE risk score discriminated risk among intermediate- and high-risk patients with ACS. Conlusions: The EuroSCORE and Parsonnet scoring systems are of no value in predicting periprocedural mortality risk in patients undergoing elective PCI LM. Overall, discriminative ability of the EuroSCORE, Parsonnet, and GRACE risk scores in unselected patients with ACS undergoing emergent PCI LM was good. In this group of patients, the EuroSCORE and Parsonnet scoring systems had no discriminative value in low and moderate risk patients. Only the GRACE risk score discriminated risk among intermediate and high risk patients. (Cardiol J 2008; 15: 268–276)

/pdf/predicted-and-observed-in-hospital-mortality-after-left-main-38cwvh3iuz.pdf

Predicted and observed in-hospital mortality after left main coronary artery stenting in 204 patients

Background : The high in-hospital mortality of patients with cardiogenic shock is being
reduced thanks to coronary interventions. The aim of the study was to evaluate the outcomes of
angioplasty and stenting in patients with cardiogenic shock caused by left main coronary
artery (LMCA) disease.
 Methods : A group of 71 consecutive patients managed for LMCA disease in an emergency
setting (38 patients in cardiogenic shock and 33 without shock symptoms) were followed up
clinically and angiographically for one year. Periprocedural and late mortality was assessed as
well as the incidence of restenosis and coronary re-interventions.
 Results : There were 17 deaths in the study population (23.9%). One-year survival in the
subgroup with cardiogenic shock was 57.9% (22 patients) with 15 periprocedural deaths and
1 death 3 months after the procedure. Restenosis and associated target lesion revascularization
were documented in 5 patients (29.4%) with and 4 patients (16.0%) without cardiogenic
shock. Multivariate analysis revealed the following independent predictors of cardiogenic shock
in patients undergoing emergency LMCA angioplasty: STEMI as the reason for intervention
(OR 14.1; 95% CI 3.71–53.7; p Conclusions : High mortality was observed in the study population, especially in the subgroup
with cardiogenic shock. Most deaths were periprocedural. Because of the high rate of restenosis,
periodical angiographic follow-up is necessary, preferably twice in the first 6 months after stent
implantation. (Cardiol J 2007; 14: 67–75)

/pdf/one-year-outcomes-of-left-main-coronary-artery-stenting-in-4iny9btnvq.pdf

One-year outcomes of left main coronary artery stenting in patients with cardiogenic shock.

Du?a czesto¶ae wystepowania choroby wiencowej i nowotworow w krajach europejskich sprawia, ?e prawie
codziennie spotyka sie osoby, u ktorych wspo³istniej± oba te schorzenia. Ich wzajemny wp³yw powoduje
zwiekszone ryzyko zarowno leczenia kardiologicznego, jak i onkologicznego. Leczenie stosowane w onkologii,
radioterapia i chemioterapia istotnie wp³ywaj± na przyspieszenie rozwoju mia?d?ycy i wyst±pienia
klinicznych objawow choroby wiencowej. Chemioterapia mo?e dodatkowo wywo³ywaae skurcz tetnic wiencowych.
Obecno¶ae choroby niedokrwiennej serca czesto ogranicza mo?liwo¶ci intensywnego leczenia nowotworu.
W takich przypadkach zabiegi rewaskularyzacyjne mog± umo?liwiae intensywniejsze leczenie
onkologiczne i poprawiae jego wyniki. Celem niniejszej pracy jest omowienie zwi±zkow miedzy chorob±
nowotworow± i chorob± wiencow± oraz zasadniczych problemow, z jakimi wi±?e sie leczenie kardiologiczne
pacjentow obci±?onych tymi chorobami.

Choroba niedokrwienna serca u pacjentów z nowotworem

Background: Many observational and randomised studies have suggested that women are referred for invasive diagnostics and treatment of coronary artery disease (CAD) less frequently than men, and the effects of percutaneous coronary intervention (PCI) among women are worse than in men. Aim: To compare direct results of PCI in men and women. Methods: The study was a retrospective assessment of case records of one thousand consecutive patients treated with PCI because of acute myocardial infarction (AMI) (344 patients), unstable angina (UA) (164 patients) and stable angina (SA) (492 patients). We examined the effects of demographic, angiographic and clinical variables on the duration of hospitalisation and in-hospital mortality separately in men and in women. Results: Women constituted 30.7% of patients treated with PCI because of AMI, 39.6% of those with UA and just 25.8% of those with SA. Women were significantly older than men, had a higher BMI, and more often suffered from hypertension and diabetes. The duration of hospitalisation was the same in men and women if the reason for PCI was SA or UA, however, in case of AMI women were hospitalised significantly longer than men. In the univariate analysis gender had no influence on in-hospital mortality regardless of the reason for PCI treatment. Among the variables subjected to multivariate analysis female gender, age, BMI, diabetes, hypercholesterolaemia, indication for PCI, final TIMI flow in the target vessel and cardiogenic shock as a complication of AMI were shown to affect mortality. Significant effects on in-hospital mortality for women were exhibited only by cardiogenic shock. Among men, indication for PCI, age, diabetes and final TIMI flow in the target vessel also had a significant influence on in-hospital mortality. Conclusions: Stable angina is a reason for performing PCI more rarely in women than in men. Women with CAD are older than men and have more risk factors. The in-hospital mortality among patients treated with PCI because of SA is independent of gender. Cardiogenic shock appeared to be the only factor that influences in-hospital mortality in women. In the case of men such an influence is also observed for indication for PCI (AMI, UA or SA), diabetes and final TIMI flow in the target vessel.

/pdf/original-article-gender-differences-and-in-hospital-3i3s134mtv.pdf

Marek Radomski

Papers

Usefulness of optical coherence tomography in the assessment of atherosclerotic culprit lesions in acute coronary syndromes. Comparison with intravascular ultrasound and virtual histology.

Predicted and observed in-hospital mortality after left main coronary artery stenting in 204 patients

One-year outcomes of left main coronary artery stenting in patients with cardiogenic shock.

Choroba niedokrwienna serca u pacjentów z nowotworem

Original article Gender differences and in-hospital mortality in patients undergoing percutaneous coronary interventions