Grzegorz Gajos

Facilitated percutaneous coronary intervention in patients with acute myocardial infarction transferred from remote hospitals

P percutaneous coronary intervention (PCI) is the preferred therapy for myocardial infarction (MI) in centers that have access to immediate invasive treatment because it confers higher patency rates, lower mortality, and lower intracranial hemorrhage rates than fibrinolysis alone.1–3 Current guidelines suggest that primary PCI could be offered as an alternative to thrombolytic therapy if performed by experienced operators within 90 30 minutes after admission.4 Recent studies have suggested that PCI for MI is superior to thrombolysis even if treatment is delayed by 120 minutes by transferring the patient to an interventional center.5,6 However, delay in restoring myocardial blood flow is known to adversely impact long-term outcome.7 If safe and feasible, restoration of myocardial blood flow by thrombolytic therapy during transfer would make longer transfer times to primary PCI acceptable without compromising myocardial salvage. In the present study we tested a combined therapy of a reduced dose of fibrinolytic drug and glycoprotein IIb/IIIa inhibitor during transfer of patients with acute MI from remote community hospitals to a routine emergency angiographic center and possible invasive treatment of MI. • • • The study was approved by the institutional review board and patients gave informed consent. Patients were enrolled at the community hospitals if: (1) they presented with an acute MI (onset of chest pain 12 hours earlier and ST elevation 1 mm in 2 contiguous electrocardiographic leads) to the emergency department of a hospital without a catheterization laboratory; (2) they had no contraindications to thrombolytic therapy and were 75 years of age; and (3) if anticipated transfer time to an interventional center was 90 minutes. Two hundred eligible patients received an IV bolus of 60 U/kg heparin (maximum 5,000), 15 mg alteplase, and 0.25 mg/kg abciximab at the remote center and were transferred, in the presence of a physician, to a single tertiary referral center for diagnostic angiography and possible PCI. Demographic data and time intervals between different stages of patient care are listed in Table 1. Infusion of alteplase (35 mg/60 min) was continued during transfer. Infusion of abciximab From the Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland. This study was financed entirely by the National Health Care Agency of Poland, Krakow Regional Division, as a part of the program to improve early detection and treatment of myocardial infarction in that region of Poland. Dr. Dudek’s address is: 2nd Department of Cardiology, Kopernika Str.17, 31-501 Krakow, Poland. E-mail: mcdudek@cyf-kr.edu.pl. Manuscript received July 8, 2002; revised manuscript received and accepted August 30, 2002. TABLE 1 Baseline Demographics, Risk Factors, Clinical Characteristics, and Time Intervals Between Different Stages of Patient Care

Ergotamine-induced cardiovascular toxicity: mechanisms and clinical significance.

concluded that an acute elevation of pulmonary capillary wedge pressure does not limit exercise capacity in CHF. In other words a patient could have a very high PCWP but a relatively good oxygen uptake. According to this Fink et al. did not found an improvement of ventilatory efficiency by acute lowering of filling pressures [9]. Our data confirm that the acute cardiac output response is the main central hemodynamic determinant of exercise capacity and not acute pressure changes. Central cardiac pressures derived from PACmeasurements cannot be deduced from the results of a CPX test and may add independent information during the evaluation of heart failure patients. We hypothesize that a subgroup of patients for example with a disparity between symptoms and results of non-invasive tests may profit from PAC procedures. A prospective study on the impact on prognosis of different non-invasive and invasive hemodynamic tests in patients with severe heart failure is warranted.

Treatment with omega-3 polyunsaturated fatty acids does not improve endothelial function in patients with type 2 diabetes and very high cardiovascular risk: A randomized, double-blind, placebo-controlled study (Omega-FMD)

BACKGROUND AND AIMS Numerous recent studies conducted in different clinical settings have focused on the benefits of omega-3 polyunsaturated fatty acids (n-3 PUFAs) in the prevention of cardiovascular diseases. There is limited evidence that patients with type 2 diabetes (T2D) and very high cardiovascular risk can also benefit from a high dose of n-3PUFAs, especially those on optimal medical therapy as recommended by the guidelines. The aim of the present study was to assess the impact of high-dose n-3 PUFA treatment on endothelial function in patients with T2D and established atherosclerotic cardiovascular disease (ASCVD). METHODS We conducted a prospective randomized double-blind, placebo-controlled, 2-center study, in which endothelial function was measured using flow-mediated dilation (FMD) and nitroglycerin-mediated dilation (NMD). Serum fatty acids composition was measured by gas chromatography. All measurements were done at baseline and after 3 months of treatment with PUFAs at a dose of 2 g/d (n = 36) or placebo (n = 38). RESULTS The majority of the study population was treated with optimal medical therapy. Despite significantly higher concentrations of eicosapentaenoic acid (EPA) and docosahexaenoic acid in the n-3 PUFA group after 3-month treatment, we did not observe significant changes in endothelial function indices (FMD and NMD). However, in regression analysis, only baseline FMD was associated with EPA concentration before 3 months of n-3 PUFA treatment. CONCLUSIONS Three months of high-dose n-3 PUFA treatment in very high-risk patients with ASCVD and T2D did not improve the endothelial function indices.

Omega-3 Polyunsaturated Fatty Acids in Patients with Coronary Disease Treated with Percutaneous Coronary Intervention

Patients with coronary artery disease who undergo percutaneous coronary intervention (PCI) are at high risk of major adverse events that might lead to increased morbidity and mortality. First, they already have occlusive atherosclerotic lesions in coronary arteries, which are to be treated with PCI with stent implantation. Second, the procedure itself might result in short- and long-term complications such as periprocedural myocardial infarction, stent thrombosis, and restenosis. Formerly, when only balloon angioplasty or bare metal stent implantation were used during PCI, restenosis was a major problem affecting up to 40% of patients. Nowadays, stents eluting antiproliferative drugs (drug eluting stent) that prevent neointimal proliferation, but also inhibit re-endothelialization stent thrombosis, become an issue. Third, catheter manipulation and stent implantation during PCI lead to overactivation of local and systemic inflammatory and prothrombotic mechanisms that might be prolonged and aggravate the chronic atherothrombosis. Last, atherosclerosis is a generalized disease and therefore PCI patients also have other lesions in coronary arteries and other vascular beds (carotid, renal, peripheral arteries) that might easily progress and lead to further events. Atherosclerosis progression is common in patients after PCI as the prevalence of risk factors (e.g., hypertension, hyperlipidemia, diabetes) in that group of patients is high. The chapter will discuss why omega-3 polyunsaturated fatty acids (PUFA) might offer beneficial effects in patients treated with PCI. The effects of omega-3 PUFA on thrombosis, atherogenesis, restenosis, endothelial function, arrhythmia and heart failure in patients after PCI will be discussed in detail.