Left ventricular dilatation and neurohumoral activation as arrhythmogenic factors in myocardial infarction : results from the Captopril And Thrombolysis Study

CE inhibition on the occurrence of early and late postinfarction ventricular arrhythmias. In addition, the associations between dilatation of the heart, activation of neurohumoral systems, and ventricular arrhythmias are evaluated in detail. Finally, noninvasive techniques, including body surface mapping and signal-averaged electrocardiography, are used to identify possible underlying electrophysiological mechanisms of the relation between dilatation and ventricular arrhythmias.

Which patient benefits from early angiotensin-converting enzyme inhibition after myocardial infarction? Results of one-year serial echocardiographic follow-up from the captopril and thrombolysis study (CATS)

Objectives. In this study we sought to investigate the effect of intervention with captopril within 6 h of the onset of myocardial infarction on left ventricular volume and clinical symptoms of heart failure in relation to infarct size during a 1-year follow-up period. Background. Remodeling of the heart starts in the early phase of myocardial infarction and is associated with an adverse prognosis, Angiotensin-converting enzyme inhibition started in the subacute or late phase after myocardial infarction has been shown to improve prognosis. Methods. In the Captopril and Thrombolysis Study, 298 patients with a first anterior myocardial infarction treated with intravenous streptokinase were randomized to receive either oral captopril (25 mg three times a day) or placebo. The left ventricular volume index was assessed by tao-dimensional echocardiography within 24 h, on days 3, 10 and 90 and after 1 year. Results. A small but significant increase in left ventricular volume indexes was observed after 12 months, Using a random coefficient model, no significant treatment effect on left ventricular volumes could be detected, In contrast, when survival models were used, the occurrence of left ventricular dilation was significantly lower in captopril-treated patients (p = 0.018), In addition, the incidence of heart failure was lower in the captopril group (p <0.03), This effect appeared early and was most obvious in patients with a medium-sized infarct (p = 0.04) and was not present in large infarcts. Conclusions. Very early treatment with captopril after myocardial infarction significantly reduces the occurrence of early dilation and the progression to heart failure, These data underscore the importance of early treatment, Furthermore, patients with intermediate infarct size benefit the most from this treatment strategy

Prognostic value of admission glucose and glycosylated haemoglobin levels in acute coronary syndromes

Background: Admission hyperglycaemia is associated with poorer prognosis in patients with an acute coronary syndrome (ACS). Whether hyperglycaemia is more important than prior long-term glucose metabolism, is unknown. Aim: To investigate the prognostic value of admission glucose and HbA(1c) levels in patients with ACS. Methods: We measured glucose and HbA(1c) at admission in 521 consecutive patients with suspected ACS. Glucose was categorized as = 11.1 mmol/l (n = 78); HbA(1c) as = 6.2% (n = 101). Mean follow-up was 1.6 +/- 0.5 years. Results: The diagnosis of ACS was confirmed in 332 patients (64%), leaving 189 (36%) with atypical chest pain. In ACS patients, mortality by glucose category (= 11.1 mmol) was 9%, 8% and 25%, respectively (p = 0.001); mortality by HbA(1c) category (= 6.2%) was 10% vs. 17%, respectively (p = 0.14). On multivariate analysis, glucose category was significantly associated with mortality (HR 3.0, 95%CI 1.1-8.3), but HbA(1c) category was not (HR 1.5, 95%CI 0.6-4.2). Discussion: Elevated admission glucose appears more important than prior long-term abnormal glucose metabolism in predicting mortality in patients with suspected ACS

Left ventricular wall motion score as an early predictor of left ventricular dilation and mortality after first anterior infarction treated with thrombolysis

To recognize patients prone to subsequent left ventricular dilation after the acute phase of a myocardial infarction treated with thrombolysis, we studied 233 patients with a first anterior infarction, treated with thrombolysis, with 2-dimensional echocardiography within 12 hours after admission and 3 months later. A wall motion score index (WMSI) and left ventricular volumes were assessed, and enzymatic infarct size was expressed as cumulative alphahydroxybutyrate dehydrogenase determined in the first 72 hours after infarction. patients who died (17 of 233, 7%) after a mean follow-up of 517 days had a significantly higher acute WMSI (2.1 +/- 0.3, mean +/- SD) than those who survived (1.9 +/- 0.4) (p=0.006),With use of this cutoff value of 2 for WMSI, ventricles with an acute WMSI less than or equal to 2 (62%) showed no increase in end-diastolic volume index (EDVI) or end-systolic volume index (ESVI), whereas ventricles with an acute WMSI >2 (38%) showed a significant increase in ESVI (6.1 +/- 12.2 ml/m(2)) and in EDVI (10.3 +/- 16.6 ml/m(2)) in the first 3 months. Using a cutoff value of 1,000 U/L for cumulative alphahydroxybutyrate dehydrogenase, only infarcts with a value of >1,000 U/L (52%) caused a significant increase in EDVI (10.8 +/- 14.3 ml/m(2)) and ESVI (6.5 +/- 10.0 ml/m(2)) in the first 3 months. Thus, acutely assessed WMSI of >2 can readily predict subsequent dilation in patients with a first anterior infarction treated with streptokinase and is a good predictor of mortality. Enzymatic infarct size also is a good predictor of dilation, although not available until 3 days after infarction

The prognostic importance of heart failure and age in patients treated with primary angioplasty

Background: Effective risk stratification is essential in the management of patients with acute myocardial infarction. Available models have not yet been studied and validated in patients treated with primary angioplasty for acute myocardial infarction. Methods: The prognostic value of heart failure defined by Killip class and age upon admission and the impact of success and failure of the angioplasty procedure was studied in 1702 consecutive patients treated with primary angioplasty. Findings: The combination of Killip class and age is a strong predictor of 30-day mortality and categorizes patients in subgroups with 30-day mortality risk ranging from 0.5 to 70%. Angioplasty failure results in a high 30-day mortality, in particular in patients with Killip class greater than or equal toII and/or age greater than or equal to70 years. A large majority of patients (72%), characterized by Killip class I and ag

Unsuccessful reperfusion in patients with ST-segment elevation myocardial infarction treated by primary angioplasty

Background Several studies have shown that patency of the epicardial vessel does not guarantee optimal myocardial perfusion in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction (STEMI). The aim of the current study was to identify clinical and angiographic correlates of unsuccessful reperfusion by the use of myocardial blush grade in a large consecutive cohort of STEMI patients. Methods Our population is represented by a total of 1548 consecutive patients with STEMI treated by primary angioplasty at our institution. All clinical and angiographic data were prospectively collected. Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow with myocardial blush grades 2 to 3. Results Poor myocardial reperfusion was observed in 358 patients (23.1%) and was associated with a significantly larger infarct size (1838 [350-3387] vs 1187 [607-2257], P <.0001) and lower ejection fraction (41 [31-48.2] vs 65 [36.5-52.5], P <.0001). At multivariate analysis, preprocedural TIMI flow 0 to 1, anterior infarction, ischemic time, postprocedural residual stenosis, advanced Killip class at presentation, and age were identified as independent predictors of poor myocardial reperfusion. At 1-year follow-up, a total of 92 patients (5.9%) had died. At multivariate analysis, including clinical and angiographic variables, unsuccessful reperfusion was an independent predictor of 1-year mortality (relative risk 3.11, 95% CI 1.99-4.87, P <.0001). Conclusions The prevalence of poor myocardial reperfusion is relatively high in patients undergoing primary angioplasty for STEMI, with a significant impact on 1-year mortality. Preprocedural TIMI flow, anterior infarction, ischemic time, Killip class at presentation, and age were independently associated with unsuccessful reperfusion. Future research should be focused on these high-risk patients, and treatment strategies should be developed to improve myocardial perfusion and clinical outcome

Hyperglycemia is an important predictor of impaired coronary flow before reperfusion therapy in ST-segment elevation myocardial infarction

OBJECTIVES This study was designed to investigate whether elevated glucose is associated with impaired Thrombolysis In Myocardial Infarction (TIMI) flow before primary percutaneous coronary intervention (PCI). BACKGROUND Reperfusion before primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) is associated with an improved outcome. Hyperglycemia in patients with STEMI is associated with an adverse prognosis. Hyperglycemia may induce a pro-thrombotic state and therefore be of influence on TIMI flow before PCI. METHODS A total of 460 consecutive patients with STEMI treated with primary PCI were included in this analysis. Hyperglycemia was defined as a glucose >= 7.8 mmol/l (140 mg/dl). RESULTS Hyperglycemia was observed in 70% and TIMI flow grade 3 before primary PCI in 17% of the patients. Patients with hyperglycemia less often had TIMI flow grade 3 before primary PCI (12% vs. 28%, p <0.001). After adjustment for differences in baseline variables, hyperglycemia was a strong predictor of absence of reperfusion before primary PCI (odds ratio 2.6, 95% confidence interval 1.5 to 4.5). CONCLUSIONS Hyperglycemia in patients with STEMI is an important predictor of impaired epicardial flow before reperfusion therapy has been initiated. Investigation of methods improving coronary flow before primary PCI in these patients is warranted. (c) 2005 by the American College of Cardiology Foundation

Pre-treatment with clopidogrel and postprocedure troponin elevation after elective percutaneous coronary intervention

Elevated troponin after elective percutaneous coronary intervention (PCl) has been associated with a worse prognosis. Pretreatment with clopidogrel may be beneficial in patients undergoing PCl. Therefore, a prospective observational study was conducted to address the potential role of clopidogrel in reducing troponin release after elective PCl.Troponin T was measured 12 hours after elective PCl in 656 patients without elevated troponin before PCl. To assess the independent association between pre-treatment with clopidogrel and increased troponin, multivariate analyses were performed. Mean age of the 656 patients was 63.5 years (SD 10.2), 194 patients (30%) were female and 114 patients (17.4%) had diabetes. In 217 patients (33%) troponin was increased after PCl. Of the 330 patients who were not pre-treated with dopidogrel, 118 patients (34%) had increased troponin after the PCl compared to 99 patients (30%) of the 326 patients who were treated with clopidogrel longer than 24 hours before the procedure (p=0.14). Stratified analyses showed that patients with older age (p=0.03), previous PCl (p=0.013), angina CCS 4 (p=0.03) and multivessel disease (p=0.04) had a significantly lower risk of troponin increase after pre-treatment with clopidogrel compared to patients without pre-treatment. After adjusting for differences in the other variables, patients who were pre-treated with clopidogrel had a significant lower risk of post-PCl increase of troponin T (odds ratio 0.69, 95% confidence interval 0.49-0.99). Pre-treatment with clopidogrel is associated with a significantly lower incidence of increased troponin after elective PCl. Combined with results of other studies, pre-treatment should be advised in patients waiting for elective PCl