David R. Cragg

Outcome of Patients with Acute Myocardial Infarction Who Are Ineligible for Thrombolytic Therapy

OBJECTIVE To determine what proportion of patients with acute myocardial infarction are not eligible for thrombolytic therapy and to assess their natural history. DESIGN Retrospective chart review. SETTING A large community-based hospital. PATIENTS All patients with acute myocardial infarction hospitalized during a 27-month period. MEASUREMENTS Of 1471 patients with acute myocardial infarction, 230 (16%) received thrombolytic therapy according to the protocol and an additional 97 (7%) received nonprotocol thrombolytic therapy, primary coronary balloon angioplasty, or both because of contraindications. The other 1144 patients (78%) did not receive reperfusion therapy. MAIN RESULTS The patients who did not receive thrombolytic therapy were older, more likely to be women, and more likely to have a history of hypertension, previous myocardial infarction, or chronic angina (all comparisons, P less than 0.002). An average of 1.9 reasons for exclusion were identified per patient among the ineligible patients. Mortality was fivefold higher among ineligible patients (19%; Cl, 16% to 21%) than among protocol-treated patients (4%; Cl, 1% to 6%) (P less than 0.001). In-hospital mortality rates for excluded patients were 28% (Cl, 23% to 32%) in elderly patients (age, greater than 76 years; n = 396); 29% (Cl, 23% to 35%) in patients with stroke or bleeding risk (n = 209); 17% (Cl, 14% to 20%) in patients with delayed presentation (greater than 4 hours after the onset of chest pain; [n = 599]); 14% (Cl, 11% to 16%) in patients with an ineligible electrocardiogram (ECG) (n = 673); and 26% (Cl, 21% to 32%) in patients with a miscellaneous reason for exclusion (n = 243). Independent predictors of increased mortality were: age greater than 76 years, stroke or other bleeding risk, ineligible ECG, or the presence of two or more exclusion criteria. CONCLUSIONS Thrombolytic therapy is currently used in the United States for only a minority of patients with acute myocardial infarction: those who have low-risk prognostic characteristics.

Randomized prospective evaluation of prolonged versus abbreviated intravenous heparin therapy after coronary angioplasty

OBJECTIVES This study was designed to prospectively evaluate the routine use of continuous heparin therapy after successful uncomplicated coronary angioplasty. BACKGROUND The use of such therapy varies among institutions and may increase the incidence of complications. Evaluation of the risks and benefits of abbreviated heparin therapy combined with early sheath removal after coronary angioplasty is necessary to determine optimal postprocedure care. METHODS We prospectively studied 284 patients who were scheduled for elective coronary angioplasty. Historical, clinical, physiologic and angiographic data were gathered. All patients received an initial bolus of heparin and then were randomized during the procedure to receive either no additional heparin therapy or an adjusted 24-h infusion. On the basis of specific criteria, additional heparin was not withheld if procedural results suggested an increased risk for complications. RESULTS Two hundred thirty-eight patients completed the study; 46 others were excluded in the catheterization laboratory because of unfavorable procedural results. The patients with abbreviated (n = 118) and 24-h (n = 120) therapy did not differ with respect to demographic and angiographic findings. However, the former had fewer bleeding complications (0% vs. 7%, p < 0.001) and were discharged earlier (mean +/- SD 23 +/- 11 h vs. 42 +/- 24 h, p < 0.001). One patient in this group had a major complication shortly after angioplasty. The mean savings in hospital charges in the abbreviated therapy group was

Comparison of outcome in patients with acute myocardial infarction aged > 75 years with that in younger patients.

1,370 (

Early hospital discharge after percutaneous transluminal coronary angioplasty

6,093 +/-

Cardiac resuscitation using emergency aortic balloon valvuloplasty

1,772 vs.

Large LV aneurysm and multiple diverticula in a patient with normal coronary arteries: another form of cardiomyopathy?

7,463 +/-

Aggressive treatment of acute myocardial infarction. Management options for various settings.

1,782, p < 0.001). CONCLUSIONS Omission of routine heparin therapy after successful coronary angioplasty reduces bleeding complications without increasing patient risk. Earlier discharge and significant cost savings are possible under proper conditions.

Acute complications associated with new-onset atrial fibrillation

Despite the advancements in reperfusion therapy, elderly patients with acute myocardial infarction (AMI) continue to have higher mortality and complication rates than younger patients. To evaluate this group we reviewed 994 consecutive patients with AMI at our hospital during a 24-month period. There were 307 patients aged > 75 years and 687 younger patients. Demographic analysis of the 2 groups showed that the elderly had a higher proportion of women (56% vs 31%, p < 0.01), more previous AMI (32% vs 23%, p < 0.01), and a higher incidence of bundle branch block (18% vs 8%, p < 0.01). Only 8% of the elderly and 36% of the younger patients were considered eligible for thrombolysis (p < 0.01). In the elderly, risk of bleeding and late presentation were the most common reasons for exclusion from treatment with thrombolytic therapy. Despite a higher proportion of non-Q-wave AMI (56% vs 44%, p < 0.01) in the elderly, the incidence of congestive heart failure (47% vs 23%, p < 0.001) and death (28% vs 11%, p = 0.001) was greater. Causes of death were not significantly different. Increased mortality in the elderly was not due to multisystem failure but to impaired myocardial reserve, suggesting that more aggressive reperfusion strategies may improve prognosis.

Angiographic risk factors for coronary restenosis following mechanical rotational atherectomy

To determine the safety and efficacy of early hospital discharge after percutaneous transluminal coronary angioplasty (PTCA), 100 patients were studied prospectively. A telemetry observation unit was established to monitor patients having uncomplicated procedures. A total of 170 lesions were dilated, with a procedural success rate of 96% and a clinical success rate of 91%. There were no deaths or patients who required emergency bypass surgery. Four patients developed abrupt vessel closure in the catheterization laboratory. No major complications developed in the telemetry observation unit or after discharge. Patients with high-risk lesion morphology, based on the American College of Cardiology/American Heart Association Task Force guidelines, tended to have a lower success rate and more procedural complications. Coronary dissections were angiographically detected in 33 patients and stratified into 6 types. To reduce possible adverse sequelae, all patients with complex dissections were triaged in the catheterization laboratory to an in-patient monitored unit for additional management. Accordingly, 20 patients were admitted to an in-patient unit for extended observation. Excluding 4 patients with myocardial infarction, 75% (12 of 16) were discharged the next day. Initial experience with early discharge suggests that under proper conditions the procedure is safe and effective. Patients with complex coronary dissections who are at high risk for abrupt vessel closure can be promptly identified after dilatation and triaged to an appropriate monitoring area. Early discharge after PTCA offers more efficient use of hospital facilities and the opportunity to reduce hospital costs.

Emergency Treatment of Cardiogenic Shock Employing Combined Iliac and Coronary Angioplasty

Abstract Percutaneous aortic valvuloplasty (PAV) is a new approach for patients who may not withstand elective surgery for valvular aortic stenosis (AS). 1,2 This procedure usually provides a significant reduction in valvular obstruction. We report the use of PAV during emergency resuscitation of a patient with acute, refractory pulmonary edema resulting in rapid recovery and subsequent elective valve replacement.