Diagnostic re-classification and prognostic risk stratification of patients with acute chest pain

Unstable angina and myocardial infarction are prevalent manifestations of acute coronary artery disease, combined in the term ‘acute coronary syndromes’. The introduction of sensitive markers for myocardial necrosis has led to confusion regarding the distinction between small myocardial infarctions and ‘true’ unstable angina, and the application of ever more sensitive markers has accelerated the pace at which patients with unstable angina are being re-classified to non-ST-segment elevation myocardial infarction. But in how many patients with acute chest pain is myocardial ischaemia really the cause of their symptoms? Numerous studies have shown that most have <5 ng/l high-sensitivity cardiac troponin, and that their prognosis is excellent (event rate <0.5% per year), incompatible with ‘impending infarction’. This marginalisation of patients with unstable angina pectoris should lead to the demise of this diagnosis. Without unstable angina, the usefulness of the term acute coronary syndromes may be questioned next. It is better to abandon the term altogether and revert to the original diagnosis of thrombus-related acute coronary artery disease, myocardial infarction. A national register should be the next logical step to monitor and guide the application of effective therapeutic measures and clinical outcomes in patients with myocardial infarction.

     

Evidence-based management of coronary artery disease in the elderly--current perspectives

Cardiovascular disease accounts for significant morbidity and mortality in the elderly. The clinical trial data available to guide therapy in this growing population subset are relatively limited. This review will focus on treatment approaches and recommendations obtained from subgroup analyses of elderly patients from major clinical trials for the management of chronic stable angina, acute coronary syndromes (unstable angina and non-ST-segment elevation myocardial infarction), and coronary revascularization. Recent advances in the treatment of stable angina have shown that use of angiotensin-converting enzyme inhibitors and lipid-lowering therapy as adjunctive measures show benefit in the elderly by reducing the occurrence of death, nonfatal myocardial infarction, and unstable angina. However, if patients experience disabling or unstable anginal symptoms despite effective medical therapy, coronary revascularization must be considered. Several clinical trials have shown a significant reduction in major adverse cardiac events when using intravenous glycoprotein receptor antagonists periprocedurally during percutaneous revascularization approaches in elderly patients with unstable angina or non-ST-segment elevation myocardial infarction, especially when these measures are performed as soon as possible. However, the success of myocardial revascularization by a percutaneous or surgical approach is highly dependent on the patient's associated comorbidities, especially in patients over age 80 years.     

Current management of unstable angina

The patient with unstable angina (angina of recent onset, of changing pattern or occurring at rest) is at high risk of myocardial infarction and sudden death. Patients with simple angina of recent onset can generally be managed out of hospital. Those with progressive angina or angina at rest should be admitted to a coronary care unit, kept at bed-rest, and given propranolol and long-acting nitrates when such therapy is indicated. With these approaches the rate of infarction within 1 to 3 months after the onset of unstable angina is about 12% (as compared with 40% before 1970); the mortality in the same period is less than 2% (as compared with 17% before 1970), though during the first year it is about 17%, much higher than in patients with stable angina and in survivors of acute myocardial infarction.Urgent aortocoronary bypass grafting has proven to be unnecessary and probably undesirable for most patients with unstable angina, and is now generally reserved for patients who continue to have angina in hospital while receiving full medical therapy. The ongoing management of patients whose angina is controlled during the acute phase remains controversial. The main options are to operate on every possible patient, to operate only on those with certain distributions of coronary artery lesions, and to operate only on those who have recurrent symptoms. Further studies are required to delineate the etiology and the Optimal management of unstable angina.     

Tissue factor, tissue factor pathway inhibitor and cytoadhesive molecules in patients with an acute coronary syndrome

The tissue factor plays a crucial role in initiating blood coagulation after plaque rupture in patients with acute coronary syndrome. It is abundant in atherosclerotic plaques. Moreover, P-selectin, some cytokines, endotoxin and immune complexes can stimulate monocytes and induce the tissue factor expression on their surface. The aim of the study was to compare plasma levels of the tissue factor, tissue factor pathway inhibitor, P-selectin, E-selectin and ICAM-1 in patients with acute myocardial infarction, unstable angina pectoris, stable coronary artery disease and normal control subjects. In addition, plasma levels of the tissue factor, tissue factor pathway inhibitor, P-selectin, E-selectin and ICAM-1 were measured in the blood withdrawn from the coronary sinus in a subgroup of patients with unstable angina pectoris and stable coronary artery disease in which the difference between concentrations in the coronary sinus and systemic blood was calculated. A significant increase in tissue factor pathway inhibitor plasma levels was detected in patients with acute myocardial infarction (373.3+/-135.1 ng/ml, p<0.01) and unstable angina pectoris (119.6+/-86.9 ng/ml, p<0.05) in contrast to the patients with stable coronary artery disease (46.3+/-37.5 ng/ml) and normal subjects (45.1+/-14.3 ng/ml). The plasma levels of tissue factor pathway inhibitor were significantly increased both in the coronary sinus and systemic blood in the patients with unstable angina pectoris. There was only a non-significant trend to higher plasma levels of the tissue factor in patients with acute myocardial infarction and unstable angina pectoris as compared to the patients with stable coronary artery disease and normal subjects, the values being 129.1+/-30.2 pg/ml, 130.5+/-57.8 pg/ml, 120.2+/-45.1 pg/ml and 124.9+/-31.8 pg/ml, respectively. Plasma levels of soluble P-selectin was only slightly, but non-significantly higher in patients with unstable angina pectoris and stable coronary artery disease (184.2+/-85.4 ng/ml and 201.6+/-67.9 ng/ml, respectively) than in patients with the acute myocardial infarction (157.4+/-88.4 ng/ml) or normal subjects (151.4+/-47.1 ng/ml). The difference in plasma levels of soluble ICAM-1 between the blood withdrawn from the coronary sinus and systemic circulation correlated significantly with the corresponding difference in plasma levels of soluble P-selectin and E-selectin. In conclusion, the tissue factor and the tissue factor pathway inhibitor play a crucial role in the initiation of arterial thrombosis. The tissue factor pathway inhibitor levels are increased both in the systemic blood and in the coronary sinus of patients with the acute coronary syndrome.     

尿微量蛋白联合血凝在冠心病诊断中的检测价值

目的:探讨尿微量蛋白联合血清纤维蛋白原在冠心病的诊断价值。方法:选取同期在我院治疗的24例稳定型心绞痛的患者,36例诊断为不稳定型心绞痛的患者和30例诊断为急性心肌梗死的患者,并选择同期30例来我院体检健康志愿者为对照组。分析以上4组患者发病时尿微量蛋白及血清纤维蛋白原的变化情况。结果:与对照组比,3个冠心病组的尿微量蛋白及血清纤维蛋白原的含量显著升高(P<0.05),与稳定型心绞痛组比,不稳定型心绞痛组的尿微量蛋白及血清纤维蛋白原的含量显著升高(P<0.05);与不稳定型心绞痛组比,急性心梗的尿微量蛋白及血清纤维蛋白原的含量显著升高(P<0.05)。3组病患的尿微量蛋白及血清纤维蛋白原之间呈正相关关系(r=0.852,P<0.05)。结论:心肌梗死和心绞痛患者尿微量蛋白及血清纤维蛋白原含量较健康成人含量高,提示尿微量蛋白及血清纤维蛋白原的含量有助于对心肌梗死和心绞痛的诊断,对急性心肌梗死的诊断价值较高。     

Unstable angina is accompanied by immune cells dysfunction

Inflammatory process has been found to play an important role in the pathogenesis of coronary heart disease (CHD) and in the prognosis of coronary artery disease (CAD) patients. The purpose of our study was to investigate some cellular immune parameters during the development of angina in the stable and the unstable stage. We have investigated the proliferative capacity of lymphocytes isolated from the peripheral blood of stable and unstable angina patients. The proliferative capacity of peripheral lymphocytes was evaluated with the radioisotopic method of tritiated thymidine incorporation. The peripheral lymphocytes present an enhanced basal proliferation of cells and lectine induced stimulation (P = 0.02/ P = 0.001), especially in the unstable angina patients, correlated with an increased population of CD4+ peripheral T-lymphocytes (P = 0.0006). The cellular immune parameters announce the development of an acute coronary syndrome. The unstable angina presents alteration of some cellular immune parameters that indicate an inflammatory syndrome associated with an increased risk of CHD, having also a prediction value for the plaque instability.     

Early and long-term outcome of elective stenting of the infarct-related artery in patients with viability in the infarct-area: Rationale and design of the Viability-guided Angioplasty after acute Myocardial Infarction-trial (The VIAMI-trial)

BACKGROUND: Although percutaneous coronary intervention (PCI) is becoming the standard therapy in ST-segment elevation myocardial infarction (STEMI), to date most patients, even in developed countries, are reperfused with intravenous thrombolysis or do not receive a reperfusion therapy at all. In the post-lysis period these patients are at high risk for recurrent ischemic events. Early identification of these patients is mandatory as this subgroup could possibly benefit from an angioplasty of the infarct-related artery.Since viability seems to be related to ischemic adverse events, we initiated a clinical trial to investigate the benefits of PCI with stenting of the infarct-related artery in patients with viability detected early after acute myocardial infarction. METHODS: The VIAMI-study is designed as a prospective, multicenter, randomized, controlled clinical trial. Patients who are hospitalized with an acute myocardial infarction and who did not have primary or rescue PCI, undergo viability testing by low-dose dobutamine echocardiography (LDDE) within 3 days of admission. Consequently, patients with demonstrated viability are randomized to an invasive or conservative strategy. In the invasive strategy patients undergo coronary angiography with the intention to perform PCI with stenting of the infarct-related coronary artery and concomitant use of abciximab. In the conservative group an ischemia-guided approach is adopted (standard optimal care).The primary end point is the composite of death from any cause, reinfarction and unstable angina during a follow-up period of three years. CONCLUSION: The primary objective of the VIAMI-trial is to demonstrate that angioplasty of the infarct-related coronary artery with stenting and concomitant use of abciximab results in a clinically important risk reduction of future cardiac events in patients with viability in the infarct-area, detected early after myocardial infarction.     

Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes

Background

Previous studies examining sex-related differences in the treatment of coronary artery disease have focused on patients in hospital. We sought to examine sex-related differences at an earlier point in care — presentation to the emergency department.

Methods

We collected data on ambulatory care and hospital admissions for 54 134 patients (44% women) who presented to an emergency department in Alberta between July 1998 and March 2001 because of acute myocardial infarction, unstable angina, stable angina or chest pain. We used logistic regression and Cox regression analyses to determine sex-specific associations between the likelihood of discharge from the emergency department or coronary revascularization within 1 year and 1-year mortality after adjusting for age, comorbidities and socioeconomic factors.

Results

Following the emergency department visit, 91.3% of patients with acute myocardial infarction, 87.4% of those with unstable angina, 40.7% of those with stable angina and 19.8% of those with chest pain were admitted to hospital. Women were more likely than men to be discharged from the emergency department: adjusted odds ratio (and 95% confidence interval [CI]) 2.25 (1.75–2.90) for acute myocardial infarction, 1.71 (1.45–2.01) for unstable angina, 1.33 (1.15–1.53) for stable angina and 1.46 (1.36–1.57) for chest pain. Women were less likely than men to undergo coronary revascularization within 1 year: adjusted odds ratio (and 95% CI) 0.65 (0.57–0.73) for myocardial infarction, 0.39 (0.35–0.44) for unstable angina, 0.35 (0.29–0.42) for stable angina and 0.32 (0.27–0.37) for chest pain. Female sex had no impact on 1-year mortality among patients with acute myocardial infarction; it was associated with a decreased 1-year mortality among patients with unstable angina, stable angina and chest pain: adjusted hazard ratio (and 95% CI) 0.60 (0.46–0.78), 0.60 (0.46–0.78) and 0.74 (0.63–0.87) respectively.

Interpretation

Women presenting to the emergency department with coronary syndromes are less likely than men to be admitted to an acute care hospital and to receive coronary revascularization procedures. These differences do not translate into worse outcomes for women in terms of 1-year mortality.For patients experiencing a new-onset acute cardiac event, the emergency department is usually the point of first contact with the health care system. A fraction of patients presenting to the emergency department are admitted to an acute care hospital for treatment or continued observation. Given that decisions made in the emergency department govern not only immediate but also longer-term treatment and outcomes, it is imperative that these decisions be appropriate.The issue of gender bias in the treatment and outcomes of coronary artery disease has been examined extensively. The current guidelines of the American College of Cardiology and American Heart Association state that the treatment of acute coronary syndromes in women should be no different from that in men.^1,2 However, several studies have found evidence to the contrary. There is general consensus that the frequency of cardiac catheterization is lower among women and that they undergo fewer revascularization procedures.^3–11 Whether these lower rates are due to an inherent gender bias or indicate appropriate care continues to be debated.Most studies of gender bias in cardiovascular care have focused either on patients in an acute care facility or on selected patient populations, such as those who have undergone cardiac catheterization. The few studies that have examined sex-specific differences in treatment decisions earlier in the process of care (i.e., in the emergency department) have either been single-centre studies¹² or have involved clinical trial patients.¹³ Moreover, examination of sex-specific differences in cardiac care has traditionally been limited to more acute conditions, such as acute myocardial infarction and unstable angina.^{5,10,11,14–21} There is a need to expand our evaluation to a wider spectrum of coronary syndromes. We undertook the current study (a) to examine differences in rates of admission to acute care hospitals between men and women presenting to the emergency department with a main ambulatory care diagnosis of acute myocardial infarction, unstable angina, stable angina or chest pain and (b) to determine whether a patient''s sex is an independent predictor of 1-year treatment and outcomes in this cohort of patients.     

Phenotype commitment in vascular smooth muscle cells derived from coronary atherosclerotic plaques: differential gene expression of endothelial nitric oxide synthase

Unstable angina and myocardial infarction are the clinical manifestations of the abrupt thrombotic occlusion of an epicardial coronary artery as a result of spontaneous atherosclerotic plaque rupture or fissuring, and the exposure of highly thrombogenic material to blood. It has been demonstrated that the proliferation of vascular smooth muscle cells (VSMCs) and impaired bioavailabilty of nitric oxide (NO) are among the most important mechanisms involved in the progression of atherosclerosis. It has also been suggested that a NO imbalance in coronary arteries may be involved in myocardial ischemia as a result of vasomotor dysfunction triggering plaque rupture and the thrombotic response. We used 5' nuclease assays (TaqMan PCRs) to study gene expression in coronary plaques collected by means of therapeutic directional coronary atherectomy from 15 patients with stable angina (SA) and 15 with acute coronary syndromes (ACS) without ST elevation. Total RNA was extracted from the 30 plaques and the cDNA was amplified in order to determine endothelial nitric oxide synthase (eNOS) gene expression. Analysis of the results showed that the expression of eNOS was significantly higher (p<0.001) in the plaques from the ACS patients. Furthermore, isolated VSMCs from ACS and SA plaques confirmed the above pattern even after 25 plating passages. In situ RT-PCR was also carried out to co-localize the eNOS messengers and the VSMC phenotype. The eNOS gene was more expressed in ACS plaques and VSMCs cultured from them, thus indicating that: a) the expression of the most important differentiation markers is retained under in vitro conditions; and b) NO may play a pivotal role in coronary artery disease. Our findings suggest a new cell system model for studying the pathophysiology of unstable angina and myocardial infarction.     

Increased Th1 activity in patients with coronary artery disease

BACKGROUND: Atherosclerotic lesions are mainly composed of macrophages and T lymphocytes. Specific T helper type 1 (Th1) cytokines and interferon gamma (IFN-gamma) inducible chemokines have been shown to be present in these lesions, modulating the local immunologic response. To explore whether this increase in Th1 activity could also be detected in circulating cells indicating a systemic activation, we studied the peripheral expression of Th1 cytokines and chemokines in patients with coronary artery disease and controls. METHODS AND RESULTS: Fifty patients with coronary artery disease (25 with unstable angina and 25 with stable angina) and 10 controls were studied. Serum interleukin (IL)-12 and IFN-gamma and the expression of IFN-gamma inducible chemokines IP-10, Mig and their receptor CXCR3 in peripheral cells were analyzed. Serum IL-12 and intracellular expression of IFN-gamma were significantly elevated in patients with unstable angina. An enhanced expression of IFN-gamma chemokines IP-10, Mig and CXCR3 in patients with stable angina was also observed. CONCLUSIONS: This study demonstrates an increased systemic inflammatory activity in patients with coronary heart disease with a predominant Th1 response, particularly in patients with unstable angina, suggesting an important role played by this polarization in plaque formation and rupture.     

Immunoscintigraphy for detecting acute myocardial infarction without electrocardiographic changes.

OBJECTIVE--To establish whether immunoscintigraphy with antibody to myosin may detect acute myocardial infarction without electrocardiographic changes. DESIGN--Prospective study of patients with suspected acute myocardial infarction or unstable angina with cardiac imaging with 111indium myosin antibody, estimation of cardiac enzyme concentrations, electrocardiography, 201thallium imaging, and radionuclide ventriculography. SETTING--Coronary care unit in a district general hospital. PATIENTS--119 Consecutive patients with suspected acute myocardial infarction or unstable angina. Patients with cardiomyopathy, myocarditis, valvular heart disease, myocardial infarction or cardiac surgery in the previous two weeks or with left bundle branch block and women of childbearing age were excluded. RESULTS--Of 75 patients with suspected acute myocardial infarction, seven had no diagnostic electrocardiographic changes despite normal conduction patterns. Immunoscintigraphy with myosin antibody disclosed necrosis in all seven patients, which was localised in regions supplied by diseased coronary arteries in all but one. Six patients had abnormal images on 201thallium imaging, and all seven had abnormal wall motion at the site of antibody uptake. One patient with minimal left main stem and right coronary artery atheroma had uptake of antibody at two discrete sites. CONCLUSIONS--Immunoscintigraphy with antibody to myosin confirms myocardial infarction in the absence of electrocardiographic changes and discloses the site of infarction.     

Immunoglobulin E and matrix metalloproteinase-9 in patients with different stages of coronary artery diseases

The aims of this study were to identify levels of total immunoglobulin E (IgE) and matrix metalloproteinase (MMP)-9 in patients with different stages of coronary artery diseases. IgE, MMP-9, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), total cholesterol, low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL) and triglyceride (TG) were measured by fluorescence enzyme immunoassay, gelatin zymography, and autoanalyzer in normal subjects (n = 40), patients with stable angina pectoris (SAP, n = 40), patients with unstable angina pectoris (UAP, n = 40), patients with acute myocardial infarction (AMI, n = 40), or post-CABG-surgery of those acute myocardial infarction (P-CABG, n = 40). Compared with normal subjects, increased IgE but unchanged MMP-9, CPK, LDH were found in SAP group and UAP group, whereas IgE, MMP-9, CPK and LDH levels were all significantly increased in AMI group. IgE, MMP-9, CPK and LDH levels in P-CABG group were significantly reduced, compared with AMI group, and were similar to those in normal subjects. Cholesterol, LDL, HDL and TG were not significantly changed in all groups. We suggest that serum total IgE can be an early marker of coronary artery disease and MMP-9 is a marker of acute myocardial infarction.     

Acute coronary syndromes following abrupt cessation of oral propranolol therapy.

Abrupt cessation of oral propranolol therapy was followed by 15 acute coronary events in 14 patients with severe angina who had been receiving propranolol in daily doses of 80 to 400 mg for periods of 7 days to 6 years. Propranolol had been stopped 1 to 14 days before each acute event because of angiographic study (seven patients), increasing symptoms (three), acute coronary insufficiency (one), asymptomatic bradycardia (one), elective surgery (one) and unknown reasons (two). Before abrupt cessation of propranolol treatment anginal symptoms had been stable in six instances but had increased in the other nine. Cessation was followed by rapid progression of symptoms prior to 11 of the 15 acute events. There were six acute transmural myocardial infarctions with three deaths, three intramural myocardial infarctions, one with ventricular fibrillation, and six episodes of acute coronary insufficiency, Unstable angina followed nine of the events and responded to propranolol therapy (160 to 320 mg/d) in eight instances. Three other patients underwent aortocoronary bypass surgery; perioperative acute myocardial infarction occurred in two. These data suggest that in a minority of patients abrupt cessation of propranolol may be hazardous, particularly in severe or unstable disease. Cessation or propranolol therapy in such patients should be gradual and closely observed. Recurrent symptoms respond to reinstitution of propranolol therapy.     

Fractional Flow Reserve Is Not Associated with Inflammatory Markers in Patients with Stable Coronary Artery Disease

Background

Atherosclerosis is an inflammatory condition and increased blood levels of inflammatory biomarkers have been observed in acute coronary syndromes. In addition, high expression of inflammatory markers is associated with worse prognosis of coronary artery disease. The presence and extent of inducible ischemia in patients with stable angina has previously been shown to have strong prognostic value. We hypothesized that evidence of inducible myocardial ischemia by local lesions, as measured by fractional flow reserve (FFR), is associated with increased levels of blood based inflammatory biomarkers.

Methods

Whole blood samples of 89 patients with stable angina pectoris and 16 healthy controls were analyzed. The patients with stable angina pectoris underwent coronary angiography and FFR of all coronary lesions.We analyzed plasma levels of cytokines IL-6, IL-8 and TNF-α and membrane expression of Toll-like receptor 2 and 4, CD11b, CD62L and CD14 on monocytes and granulocytes as markers of inflammation.Furthermore, we quantified the severity of hemodynamically significant coronary artery disease by calculating Functional Syntax Score (FSS), an extension of the Syntax Score.

Results

For the majority of biomarkers, we observed lower levels in the healthy control group compared with patients with stable angina who underwent coronary catheterization.We found no difference for any of the selected biomarkers between patients with a positive FFR (≤0.75) and negative FFR (>0.80). We observed no relationship between the investigated biomarkers and FSS.

Conclusion

The presence of local atherosclerotic lesions that result in inducible myocardial ischemia as measured by FFR in patients with stable coronary artery disease is not associated with increased plasma levels of IL-6, IL-8 and TNF-α or increased expression of TLR2 and TLR4, CD11b, CD62L and CD14 on circulating leukocytes.     

RDW和hs-CRP水平在急性心肌梗死中的表达及与冠状动脉狭窄程度的关系

目的:研究红细胞分布宽度(RDW)和高敏C反应蛋白(hs-CRP)水平在急性心肌梗死中的表达及与冠状动脉狭窄程度的关系。方法:选取2010年1月到2015年1月我院收治的急性心肌梗死患者300例(研究组),另选取单纯心绞痛患者300例(对照组),比较两组RDW、hs-CRP、Gensini评分和冠状动脉病变支数,并分析RDW、hs-CRP和Gensini评分、冠状动脉病变支数的关系。结果:研究组RDW、hs-CRP、Gensini评分和冠状动脉病变支数均显著高于对照组,两组比较差异具有统计学意义(P0.05);冠状动脉Gensini评分和病变支数与RDW、hs-CRP呈正相关关系(r=0.58,0.69,0.49,0.57,P0.05),同时RDW和hs-CRP呈正相关关系(P0.05)。结论:急性心肌梗死患者会出现RDW和hs-CRP水平增高现象,和冠状动脉狭窄程度呈正相关关系。     

Specific features of the clinical course and angiographic pattern in chronic coronary artery occlusion

Particular features of coronary angiography and clinical presentation of coronary artery disease have been studied in patients with chronic total coronary occlusion. Chronic total coronary occlusion is defined as TIMI 0 or TIMI I type flow in the artery for more than three days. Patients with coronary occlusion have more severe course of coronary artery disease: they more often suffer myocardial infarction and high gradations of angina. Myocardial function is much more affected if there is occlusion of left descending artery, or there are no signs of intercoronary collaterals.     

Focus: Sex and Gender Health: Women and Chest Pain: Recognizing the Different Faces of Angina in the Emergency Department

Emergency departments (ED) in the United States see over eight million cases of chest pain annually. While a cardinal symptom of acute coronary syndrome (ACS), multiple emergent and non-emergent causes can attribute to chest pain. This case-based perspective describes the different sex-specific causes of angina seen in ED patients. Once coronary artery disease (CAD) is ruled out with standard protocols, microvascular dysfunction is perhaps the most prevalent but under-diagnosed cause of non-CAD related angina in ED patients. Additional causes include coronary artery spasm, coronary artery dissection, coronary artery endothelial dysfunction and myocardial bridging. Non-CAD related angina is associated with persistent chest pain causing poor function, quality of life, and recidivism. Clinicians should consider additional diagnostics to routinely screen for non-CAD related causes of angina in patients with recurrent chest pain. Future work is needed to better define the epidemiological, clinical, biological, and genetic correlates of microvascular dysfunction in these patients.     

A benefit-finding intervention for family caregivers of persons with Alzheimer disease: study protocol of a randomized controlled trial

Background

Patients with ST-elevation myocardial infarction (STEMI) not treated with primary or rescue percutaneous coronary intervention (PCI) are at risk for recurrent ischemia, especially when viability in the infarct-area is present. Therefore, an invasive strategy with PCI of the infarct-related coronary artery in patients with viability would reduce the occurrence of a composite end point of death, reinfarction, or unstable angina (UA).

Methods

Patients admitted with an (sub)acute myocardial infarction, who were not treated by primary or rescue PCI, and who were stable during the first 48 hours after the acute event, were screened for the study. Eventually, we randomly assigned 216 patients with viability (demonstrated with low-dose dobutamine echocardiography) to an invasive or a conservative strategy. In the invasive strategy stenting of the infarct-related coronary artery was intended with abciximab as adjunct treatment. Seventy-five (75) patients without viability served as registry group. The primary endpoint was the composite of death from any cause, recurrent myocardial infarction (MI) and unstable angina at one year. As secondary endpoint the need for (repeat) revascularization procedures and anginal status were recorded.

Results

The primary combined endpoint of death, recurrent MI and unstable angina was 7.5% (8/106) in the invasive group and 17.3% (19/110) in the conservative group (Hazard ratio 0.42; 95% confidence interval [CI] 0.18-0.96; p = 0.032). During follow up revascularization-procedures were performed in 6.6% (7/106) in the invasive group and 31.8% (35/110) in the conservative group (Hazard ratio 0.18; 95% CI 0.13-0.43; p < 0.0001). A low rate of recurrent ischemia was found in the non-viable group (5.4%) in comparison to the viable-conservative group (14.5%). (Hazard-ratio 0.35; 95% CI 0.17-1.00; p = 0.051).

Conclusion

We demonstrated that after acute MI (treated with thrombolysis or without reperfusion therapy) patients with viability in the infarct-area benefit from a strategy of early in-hospital stenting of the infarct-related coronary artery. This treatment results in a long-term uneventful clinical course. The study confirmed the low risk of recurrent ischemia in patients without viability.

Trial registration

ClinicalTrials.gov: NCT00149591.     

冠心病患者血清尿酸、高敏C 反应蛋白、纤维蛋白原水平变化 的临床研究

目的:观察冠心病患者血清中尿酸、高敏C反应蛋白、纤维蛋白原水平的变化.方法:选取2010年11月至2011年11月于我院就诊的68例冠心病患者(稳定型心绞痛21例,不稳定型心绞痛24例,急性心肌梗死13例)作为研究对象,并选取同期于我院体检中心体检的62例健康人为对照组,检测受试者血清中尿酸、高敏C反应蛋白、纤维蛋白原的水平.结果:研究组患者血清中UA、CRP和FBG水平显著高于对照组(P＜0.05).与稳定型心绞痛组比,不稳定型心绞痛的CRP水平增高(5.34±1.98 mg/L vs.11.36±2.73 mg/L,P＜0.05),急性心肌梗死组的UA (345.63±86.4 μmol/L vs.493.76±101.2 μmol/L,P＜0.05)、CRP (5.34±1.98mg/L vs.21.3±2.24 mg/L,P＜0.05)和FBG(3.86±1.34 g/L vs.6.85±2.36 g/L,P＜0.05)水平显著增高,与不稳定型心绞痛组比,急性心肌梗死组的UA(378.91±89.7 μmol/L vs.493.76±101.2 μmol/L,P＜0.05)、CRP(11.36±2.73 mg/L vs.21.3±2.24 mg/L,P＜0.05)和FBG(4.27±2.08 g/L vs.6.85±2.36 g/L,P＜0.05)水平显著增高(P＜0.05).结论:冠心病患者血清中尿酸、高敏C反应蛋白和纤维蛋白原的水平升高,3个指标可用于评估治疗效果和预后.     

A single center experience with the newly designed R Stent in small coronary vessels

BACKGROUND: Over the past 10 years stents have been used more frequently for the treatment of de novo coronary artery stenosis. Initally these devices were used primarily in coronary arteries with diameters ranging from 3.0 to 4.0 mm. Traditionally, coronary arteries less than 3.0 mm in diameter were treated with only balloon angioplasty, due to the unavailablity of flexible, low profile, small diameter stents. In the past three years, many stents have been designed to be implanted in small coronary arteries. OBJECTIVE: The objective of this study was to evaluate the safety and feasiblity of the R Stent in patients with coronary lesions located in coronary arteries with a reference diameter 2.5-3.0 mm. METHODS AND RESULTS: Between November 1998 and September 1999, 32 patients with stable (37%) and unstable (63%) angina treated with the R Stent were included in this study. The treated lesions were in the right coronary artery (RCA) (n = 13), left cirumflex coronary artery (LCX) (n = 10), and left anterior descending coronary artery (LAD) (n = 9). Of these lesions thirteen were anatomically complex. Stent deployment was successful in 97% with one crossing failure in a patient with a vessel tortuosity of greater than 75 degrees of the circumflex artery. No post-procedual major adverse cardiac and cerebrovascular event (MACCE) occurred within 30 days of stent implantation. After the procedure, patients were scheduled for a two-week telephone follow-up and a one-month clinical evaluation. At 30 days, only one patient (3%) experienced the recurrence of angina Canadian cardiovascular society classification ((CCS) Class 2). All other patients were event and angina free. CONCLUSION: This first clinical experience in patients with small vessel disease shows that the use of the R stent is safe and feasible with low rates of acute stent thrombosis.