Objective: To investigate serial assessments of systolic coronary flow reversal in the infarct related artery for predicting poor left ventricular functional recovery after reperfused acute ...myocardial infarction. Setting: Regional hospital. Patients and methods: 49 patients with anterior acute myocardial infarction had transthoracic Doppler echocardiography to record coronary flow velocity in the left anterior descending coronary artery immediately after successful primary coronary angioplasty (day 0), and at 48 hours, one week, and three weeks. Main outcome measures: Coronary flow velocity at each time point; regional wall motion score index (RWMSI) at day 0 and at three weeks. Irreversible dysfunction was defined as a decrease in RWMSI to < 0.22. Results: Measurements of coronary flow velocity could be made in 45 patients. Patients were divided into three groups: no systolic flow reversal (group 1, n = 27), systolic flow reversal observed only on day 0 (group 2, n = 8), and systolic flow reversal persisting until 48 hours (group 3, n = 10). Although baseline RWMSI was similar among the three groups, the value at three weeks was significantly higher in group 3 than in the other two groups. In predicting irreversible dysfunction, the persistence of systolic flow reversal up to 48 hours had a higher positive predictive value (100%) than the presence of systolic flow reversal on day 0 (67%, p < 0.04). The negative predictive value of systolic flow reversal at 48 hours (83%) was comparable in accuracy to the presence of systolic flow reversal on day 0 (85%, NS). Conclusions: In reperfused anterior acute myocardial infarction, serial assessment of coronary flow velocity in the left anterior descending coronary artery is feasible using transthoracic Doppler echocardiography, and the persistence of systolic flow reversal at 48 hours is a more specific marker of irreversible dysfunction than peak creatine kinase or diastolic deceleration time.
...LV volume is the single most important predictor of survival in patients with coronary heart disease. 3 Furthermore, Gaudron and colleagues demonstrated that LV dilatation following AMI precedes ...deterioration of exercise performance and plays an active role in the development of chronic heart failure. 4 They also showed that predictors of progressive LV dilatation and chronic LV dysfunction include ventriculographic LV size, LV ejection fraction at day 4 after AMI, infarct location (especially anterior), stroke index on day 4 after AMI, and TIMI grade for the infarct related artery (IRA).
This report illustrates a magnetic resonance image of aborted myocardial infarction after primary angioplasty. Myocardial oedema in the absence of late enhancement seems to be the magnetic resonance ...marker of the myocardium at risk of infarction that has been reperfused within 30 minutes and aborted in the clinic.
Prior aspirin use has been associated with poorer outcome in acute coronary syndrome, and forms part of the TIMI Risk Score. It is not known if prior use of clopidogrel is associated with similar ...risk.
To assess if prior clopidogrel use is associated with higher risk in acute coronary syndrome.
Participants were 869 consecutive admissions to a Scottish district general hospital with suspected acute coronary syndrome.
Incidence of death, recurrent myocardial infarction or urgent percutaneous intervention at 2 weeks was recorded. Odds ratios for sub-groups on clopidogrel, aspirin or neither were calculated.
Odds ratios were: clopidogrel 1.46 (95% ci 0.62–3.33), aspirin 1.09 (95% ci 0.64–1.85), neither 0.91 (95% ci 0.53–1.54).
No definite association was shown between clopidogrel use and outcome but there was a trend towards increased risk of major acute coronary events.
Objectives. This study sought to assess predictive values of coronary flow velocity and an index of shear stress throughout the vessel for angiographic restenosis after sirolimus-eluting stent ...implantation. Design. The study patients underwent successful implantation of a sirolimus-eluting stent for de novo lesions located in native coronary vessels and underwent follow-up angiography 6-9 months later. The TIMI frame count method and quantitative digital angiographic analysis were performed based on the post-stenting angiogram. Coronary flow velocity and Reynolds number, an index of shear stress, were measured. Results. Post-stenting digital angiograms from 267 patients were analyzed. We divided the study patients into two groups: a Restenosis group with 21 patients and a Non-Restenosis group with 246 patients. The Restenosis group indicated significantly lower coronary flow velocity (137.7±35.6 mm/sec versus 241.1±72.9 mm/sec, p = 0.0001) and lower Reynolds number (107.0±35.8 versus 199.2±67.1, p = 0.0001) than did the Non-Restenosis group. Conclusions. Lowered coronary flow velocity and shear stress after sirolimus-eluting stenting may predict the risk of restenosis.
Objective: To evaluate the association between baseline homocysteine concentrations and restenosis rates in patients electively undergoing their first percutaneous coronary intervention (PCI) without ...stenting. Design: Prospective, single centre, observational study. Setting and patients: Patients electively undergoing their first PCI without stenting at a tertiary referral centre between 1990 and 1998. Methods: Blood samples were collected from all patients at baseline and assayed to determine the patients’ homocysteine concentrations. Patients whose PCI was successful underwent repeat angiography at a median of 6.4 (interquartile range 6–6.8) months. Their baseline and follow up angiograms were compared by quantitative coronary angiography to assess the incidence of restenosis. For the analysis, the patients were divided into two groups based on whether their baseline homocysteine concentrations were above or below the median value. These two groups were compared to determine whether there was any association between their baseline homocysteine concentrations and the incidence of restenosis at six months. Results: 134 patients had a successful first PCI without stenting (involving 200 lesions). At six month angiography, restenosis was observed in 33 patients (49.3%) with baseline homocysteine concentrations above the median value and in 31 patients (46.3%) with concentrations below the median value (p = 0.74). There was no difference in the percentage of lesions developing restenosis (38 (39.6%) v 40 (38.5%), respectively, p = 0.87) or late lumen loss (0.40 mm v 0.31 mm, respectively, p = 0.24). On multivariable analysis, there was no association between homocysteine concentrations and late lumen loss (r = −0.11, p = 0.11) or the percentage diameter stenosis at follow up (r = −0.07, p = 0.32). Conclusion: Baseline homocysteine concentrations were not associated with six month restenosis rates in patients electively undergoing their first PCI without stenting.
SUMMARY Background We compared the thrombolysis in myocardial infarction (TIMI) frame count and examined the impact of angioplasty on the count between patients with normal coronary angiograms and ...those with single-vessel disease (SVD). Methods In 780 consecutive patients referred for coronary angiography, TIMI frame count was measured for 149 patients who had SVD and 32 patients with normal angiograms who underwent the procedure for electro-physiologic study or valvular heart disease survey. Results Comparison of each of the three vessels in the normal vessel group with the corresponding non-stenotic vessels in the SVD group showed similar counts in each of the left anterior descending artery (LAD), left circumflex artery (LCX), and right coronary artery (RCA). For the stenotic vessels, after successful angioplasty, the counts were all reduced (LAD, 54.5 ±28.8 vs. 34.0 ±19.3; LCX, 67.3 ±31.1 vs. 34.1 ±19.0; RCA, 33.2 ±28.1 vs. 19.3 ±7.9; all p <0.05). In addition, the count in the RCA after angioplasty was lower, compared with the RCA of the normal group (19.3 ±7.9 vs. 29.1 ±14.6, p = 0.001). Multivariate analysis showed that the use of oral calcium channel blockers was the only independent predictor for the reduction in RCA after angioplasty. Conclusion In patients with SVD, the data of TIMI frame count in the nonstenotic vessels were similar to those without the disease, suggesting that the count in the normal artery is not affected by the adjacent stenotic artery. For the stenotic vessels, angioplasty had differential effects on each of the three arteries, indicating the existence of distinct properties, which is affected by calcium channel blockers, for individual coronary arteries in response to atherosclerosis and/or angioplasty.
A comprehensive appraisal was undertaken on behalf of the British Cardiac Society and the Royal College of Physicians of London to assess the use of clopidogrel in acute coronary syndromes. The ...appraisal was submitted to the National Institute for Clinical Excellence (NICE) in August 2003 and contributed to the development of the recently published guidelines for the use of clopidogrel in acute coronary syndromes. The submission to NICE and more recent publications evaluating the use of clopidogrel are reviewed.
Objective: To investigate whether the myocardial performance index (MPI) can predict left ventricular functional outcome in patients with early recanalisation after anterior acute myocardial ...infarction (MI) and to determine when the index should be measured. Design: MPI was measured serially by two dimensional Doppler echocardiography after successful percutaneous coronary intervention (PCI). Left ventricular function was evaluated by echocardiography and left ventriculography. To assess coronary microvascular damage, the coronary flow velocity pattern was measured immediately after PCI with a Doppler guidewire. Setting: Hiroshima City Asa Hospital. Patients: 32 consecutive patients with their first anterior acute MI who had complete occlusion of left anterior descending coronary artery. Interventions: Successful PCI within six hours of symptom onset. Main outcome measures: Left ventricular anterior wall motion score index (A-WMSI), left ventricular end diastolic pressure (LVEDP), left ventricular ejection fraction (LVEF), and left ventricular end diastolic volume (LVEDV). Results: There was a significant negative correlation between MPI on day 2 and the coronary diastolic deceleration time (r = −0.66, p < 0.002), as well as a significant positive correlation with the coronary diastolic deceleration rate (r = 0.74, p < 0.0001). MPI on day 2 was significantly correlated with the short and long term changes of A-WMSI and with the short term changes of LVEDP. Furthermore, MPI on day 2 was significantly correlated with the short and long term changes of LVEF (r = −0.52, p < 0.003, and r = −0.64, p < 0.0008, respectively) and of LVEDV (r = 0.51, p < 0.003, and r = 0.41, p < 0.05, respectively). Conclusions: Doppler derived MPI on day 2, representative of the early coronary microvascular state, can predict the left ventricular functional outcome after early successful recanalisation of a patient’s first anterior acute MI.
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