Martin Gottwik

Visualization of coronary artery anomalies and their anatomic course by contrast-enhanced electron beam tomography and three-dimensional reconstruction☆

Anomalous coronary arteries are rare conditions. However, they may cause myocardial ischemia and sudden death and their reliable identification is crucial for any imaging method that attempts coronary artery visualization. We studied the ability of contrast-enhanced electron beam tomography (EBT) to identify anomalous coronary arteries and their course. Thirty patients with previously identified coronary anomalies and 30 subjects with normal coronary anatomy were studied. By EBT, 40 to 50 axial images of the heart (3-mm slice thickness, 1 mm overlap, electrocardiographic trigger) were acquired in a single breathhold during continuous injection of contrast agent (160 ml, 4 ml/s). Based on the original images and 3-dimensional reconstructions, the EBT data were analyzed by 2 blinded observers as to the presence of coronary anomalies and their course. Results were compared with invasive angiography. EBT correctly identified all normal controls and all patients with coronary anomalies. The anatomic course of the coronary anomalies was correctly classified in 29 of 30 patients (97%), including right-sided origin of the left main coronary artery (n = 4) or of the left circumflex coronary artery (n = 15), left-sided origin of the right coronary artery (n = 9), and 1 coronary fistula from the left circumflex coronary artery to the right atrium. Only the distal anastomosis of a second fistula from the left circumflex coronary artery to a bronchial artery was not correctly identified. This study demonstrates that contrast-enhanced EBT is a reliable noninvasive technique to identify anomalous coronary arteries and their course.

Intravenous Recombinant Tissue Plasminogen Activator (rt-PA) and Urokinase in Acute Myocardial Infarction: Results of the German Activator Urokinase Study (GAUS)

The effects of recombinant tissue plasminogen activator (rt-PA) and urokinase on patency and early reocclusion of infarct-related coronary arteries were investigated in a single blind, randomized multicenter trial in 246 patients with acute myocardial infarction of less than 6 h duration. Both 70 mg of single chain rt-PA with an initial bolus of 10 mg and 3 million units of urokinase with an initial bolus of 1.5 million units were given intravenously over 90 min. The first angiographic study at the end of the infusion revealed a patent infarct-related artery (Thrombolysis in Myocardial Infarction trial [TIMI] grade 2 or 3) in 69.4% of 121 patients given rt-PA versus 65.8% of 117 patients given urokinase (p = NS). Among patients treated within 3 h from symptom onset a patent infarct-related artery was found in 63.9% of 72 patients given rt-PA versus 70% of 70 patients given urokinase (p = NS). There were five cardiac deaths in each group and one fatal intracranial hemorrhage in the rt-PA group. The in-hospital reinfarction rate was 8.9% versus 13.2% for patients treated with rt-PA and urokinase, respectively. There was no difference in left ventricular function at baseline and follow-up catheterization studies. Both drugs were well tolerated and there was no significant difference in cardiovascular or bleeding complications between the two groups. It is concluded that rt-PA and urokinase in the dosages used provide similar efficacy and safety in the treatment of acute myocardial infarction. Reocclusion during the first 24 h may be less frequent after urokinase treatment.

In-hospital time to treatment of patients with acute ST elevation myocardial infarction treated with primary angioplasty: determinants and outcome. Results from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte

Objective: To determine the predictors of time between presentation and primary angioplasty and the influence of this delay time on in-hospital mortality in clinical practice. Design: Analysis of data from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK). Patients: Data of 4815 patients registered at 80 hospitals between 1994 and 2000 were analysed. Results: Mean age of the patients was 61.4 (12.5) years. Cardiogenic shock was present in 14.1%. Mean time from admission to primary angioplasty (“door to angiography” time) was 83 (122) minutes. Logistic regression analysis showed the presence of a bundle branch block (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.15 to 3.29), prior coronary artery bypass grafting (OR 1.67, 95% CI 1.08 to 2.59), pre-hospital delay > 3 hours (OR 1.61, 95% CI 1.37 to 1.89), and female sex (OR 1.21, 95% CI 1.01 to 1.45) to be independently associated with longer door to angiography times, whereas a higher hospital volume of performing primary angioplasty (OR 0.53, 95% CI 0.46 to 0.62) and the year of the investigation (OR 0.96, 95% CI 0.92 to 1.00) were independently associated with shorter door to angiography times. Independent predictors of in-hospital mortality were cardiogenic shock (41.6% v 4.0% without cardiogenic shock, p < 0.0001), technical success (29.2% with TIMI (thrombolysis in myocardial infarction) flow < 3 v 6.5% with TIMI flow 3, p < 0.0001), age (16.5% ⩾ 70 years v 6.6% < 70, p < 0.0001), three vessel disease (16.5% v 6.8% with < 3 vessel disease, p < 0.0001), anterior location of infarction (12% v 7.4% without anterior infarction, p < 0.0001), year of inclusion (adjusted OR 0.92 per year, p  =  0.011), and volume of primary angioplasty at the hospital (11% for < 20 angioplasty procedures/year v 8.3% for ⩾ 20/year, p  =  0.027) but not the door to angiography time (adjusted OR 1.14 per tertile, p  =  0.397). Conclusions: In current clinical practice in Germany median door to angiography time is quite short (83 (122) minutes). Some patients and hospital factors are independently associated with a longer door to angiography time. Within the observed short in-hospital delays door to angiography time did not influence in-hospital mortality. However, efforts to keep them as short as possible should be continued.

Comparison of primary angioplasty with conservative therapy in patients with acute myocardial infarction and contraindications for thrombolytic therapy

The benefit of primary angioplasty in patients with acute myocardial infarction (AMI) and contraindications for thrombolysis compared to a conservative regimen is still unclear. Out of 5,869 patients with AMI registered by the MITRA trial, 337 (5.7%) patients had at least one strong contraindication for thrombolytic therapy. Out of these 337 patients 46 (13.6%) were treated with primary angioplasty and 276 (86.4%) were treated conservatively. Patients treated conservatively were older (70 years vs. 60 years; P = 0.001), had a higher rate of a history with chronic heart failure (14.8% vs. 4.4%; P = 0.053), a higher heart rate at admission (86 beats/min vs. 74 beats/min; P = 0.001), and a higher prevalence of diabetes mellitus (27.1% vs. 12.8%; P = 0.056). Patients treated with primary angioplasty received more often aspirin (91.3% vs. 74.6%; P = 0.012), β‐blockers (60.9% vs. 46.1%; P = 0.062), angiotensin converting enzyme (ACE) inhibitors (71.7% vs. 44%; P = 0.001), and the so‐called optimal adjunctive medication (54.4% vs. 32.3%; P = 0.004). Hospital mortality was significantly lower in patients who received primary angioplasty (univariate: 2.2% vs. 24.7%; P = 0.001; multivariate: OR = 0.46; P = 0.0230). In patients with AMI and contraindications for thrombolytic therapy, primary angioplasty was associated with a significantly lower mortality compared to conservative treatment. Therefore, hospitals without the facilities to perform primary angioplasty should try to refer such patients to centers with the facilities for such a service, if this is possible in an acceptable time.Cathet. Cardiovasc. Intervent. 46:127–133, 1999.

Antibiotic Therapy After Acute Myocardial Infarction

Background—Infection with Chlamydia pneumoniae is suspected to contribute to the pathogenesis of human atherosclerosis. We investigated whether treatment with the macrolide antibiotic roxithromycin would reduce mortality or morbidity in patients with an acute myocardial infarction. Methods and Results—Eight hundred seventy-two patients with an acute myocardial infarction (AMI) were randomly assigned to receive double-blind treatment with either 300 mg roxithromycin or placebo daily for 6 weeks. Primary end point was total mortality during 12-month follow-up. Four hundred thirty-three patients were treated with roxithromycin and 439 with placebo. With the exception of a higher proportion of patients suffering an anterior wall AMI (48.1% in the roxithromycin group versus 40.2% in the placebo group;P =0.027) and a lower prevalence of chronic obstructive pulmonary disease in the roxithromycin group (3.5% versus 6.9%, P =0.028), baseline characteristics, reperfusion therapy, and medical treatment were well balanced between the two groups. More patients in the roxithromycin group interrupted their study medication before completion of at least 4 weeks of treatment (78 of 433 [18%] versus 48 of 439 [11%];P =0.003; odds ratio, 1.8; 95% CI, 1.2 to 2.6). Follow-up at 12 months was achieved in 868 of 872 (99.5%) patients. Total mortality at 12 months was 6.5% (28 of 431) in the roxithromycin group compared with 6.0% (26 of 437) in the placebo group (odds ratio, 1.1; 95% CI, 0.6 to 1.9;P =0.739). There were also no differences in the secondary combined end points at 12 months. Conclusions—Treatment of AMI patients with roxithromycin did not reduce event rates during 12 months of follow-up. Therefore, our findings do not support the routine use of antibiotic treatment with a macrolide in patients with AMI.

Volume–outcome relation for contemporary percutaneous coronary interventions (PCI) in daily clinical practice: is it limited to high-risk patients? Results from the Registry of Percutaneous Coronary Interventions of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

Objective: The formerly observed volume–outcome relation for percutaneous coronary interventions (PCIs) has recently been questioned. Design: We analysed data of the PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte. Patients: In 2003 a total of 27 965 patients at 67 hospitals were included. Results: The median PCI volume per hospital was 327. In-hospital mortality was 1.85% in hospitals belonging to the lowest PCI volume quartile and 1.21% in the highest quartile (p for trend <0.001). Two groups of patients were then compared according to their treatment at hospitals with either <325 PCIs (n = 5754) or >325 PCIs (n = 22 211) per year. Logistic regression analysis showed that a PCI performed at hospitals with a volume of >325 PCI/year was independently associated with a lower hospital mortality (OR = 0.67, 95% CI: 0.52 to 0.87; p = 0.002). If PCI was performed in patients with acute myocardial infarction there was a significant decline in mortality with increasing volume (p for trend = 0.004); however, there was no association in patients without a myocardial infarction. Conclusions: This analysis of contemporary PCI in clinical practice shows a small but significant volume–outcome relation for in-hospital mortality. However, this relation was only apparent in high-risk subgroups, such as patients presenting with acute myocardial infarction.

Incications and complications of invasive diagnostic procedures and percutaneous coronary interventions in the year 2003. Results of the quality control registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK).

Im ALKK-Register werden etwa 20% der invasiven und interventionellen kardiologischen Prozeduren in der Bundesrepublik Deutschland erfasst. Im Jahr 2003 wurden in 75 Kliniken 82 282 konsekutive invasive diagnostische und 30 689 interventionelle Prozeduren erfasst und zentral ausgewertet. Die Hauptindikation zur Koronarangiographie war in 92,5% eine KHK, in 1,6% eine Myokarderkrankung mit EF <40%, in 4,0% ein Vitium und in 1,9% sonstige kardiale Erkrankungen. Ein akutes koronares Syndrom lag bei 25% der Patienten vor. Die Komplikationsrate bei alleiniger invasiver Diagnostik war mit <0,5% schweren Komplikationen gering. Die Indikation zur PCI (n=30 689) war eine stabile Angina pectoris in 44,1%, ein STEMI in 22,3%, ein NSTEMI in 14,8%, eine instabile Angina in 10,0%, eine stumme Ischämie in 2,2%, eine prognostische in 5,2% der Fälle. In der Mehrzahl der Fälle wurde die PCI als Prima-vista Intervention im Rahmen der diagnostischen Untersuchung durchgeführt (n=23 887=78,6%). Die Intervention war erfolgreich in 94,6% der Fälle. Eine Stentimplantation erfolgte bei 77,2% der Interventionen, wobei 1 Stent bei 88,4%, 2 bei 7,6% und 3 oder mehr Stents bei 3,3% implantiert wurden. Ein medikamentenbeschichteter Stent wurde nur bei 3,6% der Patienten implantiert. Die Komplikationen nach PCI war im Wesentlichen von der Indikation zur Intervention abhängig. Die Sterblichkeit im Krankenhaus war bei Patienten mit kardiogenem Schock mit 33% am höchsten und betrug bei Patienten mit stabiler Angina, stummer Ischämie und prognostischer Indikation um die 0,2%. Zusammenfassend ist zu sagen, dass im ALKK-Register weiter eine Zunahme von invasiver Diagnostik und Interventionen bei Patienten mit akuten koronaren Syndromen zu beobachten ist. Die PCIs werden bei 3/4 der Patienten sofort nach der Diagnostik durchgeführt. Die Stent Rate scheint bei etwa 80% der PCIs an einem Plateau angelangt zu sein, wobei drug-eluting Stents bisher nur in wenigen Fällen angewendet werden. Die Komplikationsrate nach PCI ist im Wesentlichen von der Indikation abhängig. The ALKK registry contains about 20% of the invasive and interventional cardiological procedures performed in Germany. In 2003 a total of 82,282 consecutive diagnostic invasive and 30,689 interventional procedures from 75 hospitals were centrally collected and analyzed. The main indication for an invasive diagnostic procedure was coronary artery disease in 92.5% of cases, myocardial disease in 1.6%, impaired left ventricular function in 4.0%, valve disease in 4% and other indications in 1.9%. An acute coronary syndrome was present in 25% of the patients. The rate of severe complications in patients with a lone diagnostic invasive procedure was low (<0.5%). The indication for percutaneous coronary intervention (n=30,689) was stable angina in 44.1%, ST elevation myocardial infarction in 22.3%, non ST elevation myocardial infarction in 14.8%, unstable angina in 10.0%, silent ischemia in 2.2%, prognostic in 5.2% of patients. The majority of interventions were performed directly after the diagnostic procedure (n=23,887=78.6%). The intervention was successful in 94.6% of cases. Stent implantation was performed in 77.2%, with 1 stent in 88.4%, two stents in 7.6% and 3 or more stents in 3.3%. A drug-eluting stent was implanted in 3.6% of the cases. The complication rate after PCI was influenced by the indication for the intervention. The in-hospital mortality in patients with cardiogenic shock was 33%, while in patients with stable angina, silent ischemia and prognostic indication only 0.2% died. There is an increase of invasive diagnostic and interventional procedures in patients with acute coronary syndromes, with 47% of PCIs performed in these patient. PCIs were performed in 75% of the cases directly after the diagnostic procedure. The rate of stent implantation seems to have reached a plateau at around 80%, while drug-eluting stents were implanted only in a minority of cases. The complication rate is mainly dependent on the clinical presentation of the patients and the indication for PCI.

Incications and complications of invasive diagnostic procedures and percutaneous coronary interventions in the year 2003

Im ALKK-Register werden etwa 20% der invasiven und interventionellen kardiologischen Prozeduren in der Bundesrepublik Deutschland erfasst. Im Jahr 2003 wurden in 75 Kliniken 82 282 konsekutive invasive diagnostische und 30 689 interventionelle Prozeduren erfasst und zentral ausgewertet. Die Hauptindikation zur Koronarangiographie war in 92,5% eine KHK, in 1,6% eine Myokarderkrankung mit EF <40%, in 4,0% ein Vitium und in 1,9% sonstige kardiale Erkrankungen. Ein akutes koronares Syndrom lag bei 25% der Patienten vor. Die Komplikationsrate bei alleiniger invasiver Diagnostik war mit <0,5% schweren Komplikationen gering. Die Indikation zur PCI (n=30 689) war eine stabile Angina pectoris in 44,1%, ein STEMI in 22,3%, ein NSTEMI in 14,8%, eine instabile Angina in 10,0%, eine stumme Ischämie in 2,2%, eine prognostische in 5,2% der Fälle. In der Mehrzahl der Fälle wurde die PCI als Prima-vista Intervention im Rahmen der diagnostischen Untersuchung durchgeführt (n=23 887=78,6%). Die Intervention war erfolgreich in 94,6% der Fälle. Eine Stentimplantation erfolgte bei 77,2% der Interventionen, wobei 1 Stent bei 88,4%, 2 bei 7,6% und 3 oder mehr Stents bei 3,3% implantiert wurden. Ein medikamentenbeschichteter Stent wurde nur bei 3,6% der Patienten implantiert. Die Komplikationen nach PCI war im Wesentlichen von der Indikation zur Intervention abhängig. Die Sterblichkeit im Krankenhaus war bei Patienten mit kardiogenem Schock mit 33% am höchsten und betrug bei Patienten mit stabiler Angina, stummer Ischämie und prognostischer Indikation um die 0,2%. Zusammenfassend ist zu sagen, dass im ALKK-Register weiter eine Zunahme von invasiver Diagnostik und Interventionen bei Patienten mit akuten koronaren Syndromen zu beobachten ist. Die PCIs werden bei 3/4 der Patienten sofort nach der Diagnostik durchgeführt. Die Stent Rate scheint bei etwa 80% der PCIs an einem Plateau angelangt zu sein, wobei drug-eluting Stents bisher nur in wenigen Fällen angewendet werden. Die Komplikationsrate nach PCI ist im Wesentlichen von der Indikation abhängig. The ALKK registry contains about 20% of the invasive and interventional cardiological procedures performed in Germany. In 2003 a total of 82,282 consecutive diagnostic invasive and 30,689 interventional procedures from 75 hospitals were centrally collected and analyzed. The main indication for an invasive diagnostic procedure was coronary artery disease in 92.5% of cases, myocardial disease in 1.6%, impaired left ventricular function in 4.0%, valve disease in 4% and other indications in 1.9%. An acute coronary syndrome was present in 25% of the patients. The rate of severe complications in patients with a lone diagnostic invasive procedure was low (<0.5%). The indication for percutaneous coronary intervention (n=30,689) was stable angina in 44.1%, ST elevation myocardial infarction in 22.3%, non ST elevation myocardial infarction in 14.8%, unstable angina in 10.0%, silent ischemia in 2.2%, prognostic in 5.2% of patients. The majority of interventions were performed directly after the diagnostic procedure (n=23,887=78.6%). The intervention was successful in 94.6% of cases. Stent implantation was performed in 77.2%, with 1 stent in 88.4%, two stents in 7.6% and 3 or more stents in 3.3%. A drug-eluting stent was implanted in 3.6% of the cases. The complication rate after PCI was influenced by the indication for the intervention. The in-hospital mortality in patients with cardiogenic shock was 33%, while in patients with stable angina, silent ischemia and prognostic indication only 0.2% died. There is an increase of invasive diagnostic and interventional procedures in patients with acute coronary syndromes, with 47% of PCIs performed in these patient. PCIs were performed in 75% of the cases directly after the diagnostic procedure. The rate of stent implantation seems to have reached a plateau at around 80%, while drug-eluting stents were implanted only in a minority of cases. The complication rate is mainly dependent on the clinical presentation of the patients and the indication for PCI.

Ballondilatation beim akuten Herzinfarkt im klinischen Alltag : Ergebnisse des Registers der Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK) bei 4625 Patienten

Wir berichten über die Ergebnisse der Ballondilatation beim akuten Myokardinfarkt (AMI) an großen kommunalen Kliniken zwischen 1992 und 1995. An 68 Zentren der ALKK wurden in diesem Zeitraum 4625 Dilatationen im Rahmen eines AMI durchgeführt. Das Alter der Patienten betrug 60,8 ± 11,3 Jahre, und es handelte sich in 75,1% der Fälle um Männer. Das Infarktgefäß war in 43% der Ramus interventricularis anterior, in 37% die Arteria coronaria dextra, in 16% die Arteria circumflexa, in 2,3% ein Bypassgefäß und in 1,4% der Hauptstamm der linken Koronararterie. Nach der Intervention wurde die Residualstenose in 86% der Fälle mit weniger als 50% beurteilt. In den verschiedenen Zentren wurden zwischen einer und 365 Infarktdilatationen durchgeführt, mit einem Median von 40 Infarktdilatationen pro Jahr und Zentrum. Der Anteil der Infarktdilatationen an allen durchgeführten Interventionen stieg von 5,2% 1992 auf 5,9% 1995 an (p = 0,01). Die Zahl der lokalen Komplikationen betrug 3,2%. Bei 1,1% der Untersuchungen erfolgte eine chirurgische Intervention am Gefäßzugang. Bei 273 (5,9%) der Patienten wurde während des Klinikaufenthaltes eine zweite Ballondilatation durchgeführt, eine aortokoronare Bypassoperation bei insgesamt 3% der Patienten. Während des Klinikaufenthaltes verstarben 438 (9,5%) der 4625 Patienten. Die Mortalitätsrate blieb über die Jahre hinweg konstant (1992: 10,6%; 1993: 8,6%; 1994: 9,7%; 1995: 9,8%: p = ns). Eine höhere Mortalität ergab sich bei älteren Patienten, bei Patienten mit einer Dreigefäßerkrankung, wenn das Infarktgefäß der Ramus interventricularis anterior oder ein Bypassgefäß war und bei schlechtem Ergebnis der Ballondilatation, d.h. einer Residualstenose über 50%. Krankenhäuser, an denen mehr als 40 Infarktdilatationen pro Jahr durchgeführt wurden, hatten eine niedrigere Mortalität. Im klinischen Alltag eines großen Spektrums interventionell tätiger kardiologischer Zentren lassen sich die Ergebnisse der Ballondilatation beim AMI bezüglich Mortalität, technischer Erfolgsrate und Komplikationen mit denen an hochspezialisierten Zentren vergleichen. Balloon angioplasty as the treatment of first choice in the setting of an acute myocardial infarction (AMI) is gaining widespread acceptance because of favourable results from specialised centres concerning high patency rates and low mortality. This study reports the results of angioplasty for AMI at large community hospitals during 1992–1995. 4625 procedures were performed at 68 centres of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK). The age of the patients was 60,8 ± 11,3 years, with 75,1% men. The infarct related artery was the left anterior descendent in 43%, the right coronary artery in 37%, the circumflex artery in 16%, a bypass graft in 2,3% and the left main stem in 1,4% of patients. The success rate (residual stenosis < 50%) of the intervention was 86%. There was a wide range of procedures per centre, with a median of 40 AMI angioplasties per year and centre. The amount of angioplasties for AMI in relation to all angioplasties performed during this period rose from 5,2% in 1992 to 5,9% in 1995 (p = 0,01). Local complications at the puncture site occurred in 3,2%, with the need for a surgical intervention in 1,1% of patients. In 273 (5,9%) of the patients a second angioplasty was performed during the hospital stay. Aortocoronary bypass surgery was performed in 3% of the patients. Hospital mortality was 9,5% (438/4625 patients). The mortality rate remained constant during the years investigated (1992: 10,6%; 1993: 8,6%; 1994: 9,7%; 1995: 9,8%: p = ns). Higher mortality was observed in older patients, patients with multiple vessel disease, the left anterior descending artery or a bypass graft as infarct related artery as well as in patients with failed reperfusion (residual stenoses > 50%). Hospitals with a case load of more than 40 angioplasties for AMI per year showed a lower mortality as compared to the others. In clinical practice at large community hospitals results of angioplasty for AMI concerning mortality, complications and technical success rate are comparable to those of highly specialised centres. The absolute numbers of angioplasties for AMI increased constantly over the years.

Incidence, risk factors, and clinical outcome of stroke after acute myocardial infarction in clinical practice☆

: In this analysis of ischemic and hemorrhagic strokes after acute myocardial infarction (AMI) in 21,330 consecutively included patients with AMI, we found an incidence of stroke after AMI of 1.2% and a very poor prognosis. Previous stroke, atrial fibrillation, and older age were the strongest predictors of stroke after AMI; thrombolysis was a borderline risk factor and early therapy with aspirin was associated with a reduction in stroke after AMI.