Spyros K. Argyrakis

The impact of treatment with omeprazole on the effectiveness of clopidogrel drug therapy during the first year after successful coronary stenting.

BACKGROUND Because clopidogrel is converted to its active metabolite by P450 isoenzymes, which are also involved in the metabolism of omeprazole, there is concern regarding whether the action of clopidogrel would be reduced in patients also taking omeprazole. OBJECTIVE To evaluate the impact of omeprazole administration on the effectiveness of clopidogrel drug therapy during the first year following successful coronary stenting (CS). METHODS A total of 588 consecutive patients who underwent successful CS for stable or unstable coronary artery disease were studied. Patients were classified into those who were treated (group A, n=340) or not treated (group B, n=248) with omeprazole for seven or more consecutive days during the entire observation period. The composite of cardiac death or rehospitalization for nonfatal myocardial infarction during the first year was the prespecified primary study end point. RESULTS Baseline characteristics, and dual clopidogrel and acetylsalicylic acid drug therapy were well balanced between the study groups. By one year, the primary end point was reached by 58 (9.9%) patients, including 20 (3.4%) who died due to cardiac reasons and 38 (6.5%) who were rehospitalized because of a nonfatal myocardial infarction. Patients in groups A and B, respectively, were at similar risk of the primary composite end point (10% versus 9.7%, hazard ratio 1.1 [95% CI 0.6 to 1.8]; P=0.89). CONCLUSIONS According to the results of the present study, treatment with omeprazole had no impact on the clinical efficacy of clopidogrel drug therapy during the first year after successful CS.

The significance of circulating levels of both cardiac troponin I and high-sensitivity C reactive protein for the prediction of intravenous thrombolysis outcome in patients with ST-segment elevation myocardial infarction

Objectives: To evaluate, using continuous 12-lead ECG ST-segment monitoring, the role of circulating levels of both cardiac troponin I (cTnI) and high-sensitivity C reactive protein (hs-CRP), on presentation, in the prediction of intravenous thrombolysis outcome in patients with ST-segment elevation myocardial infarction (STEMI). Design and setting: Prospective observational study in a tertiary referral centre. Patients: 786 consecutive patients with STEMI, who received intravenous thrombolysis in the first 6 h from index pain. Main outcome measures: The incidence of failed thrombolysis and of cardiac death by 30 days. Failed thrombolysis was defined as the absence of abrupt and sustained ⩾50% ST-segment recovery in the first 90 min after the initiation of intravenous thrombolysis. Results: The incidence of failed thrombolysis and 30-day cardiac death was 57.4% and 11.8%, respectively. By multivariate logistic regression analysis according to tertiles of both cTnI (RR, 1.5; 95% CI 1.1 to 1.8, p = 0.004 for highest vs middle third; 2.2, 1.9 to 3.5, p<0.001 for highest vs lowest third; 1.5, 1.2 to 1.8, p = 0.001 for middle vs lowest third) and hs-CRP (RR, 2.0, 95% CI, 1.6 to 2.2; p<0.001 for highest vs middle third; 2.6, 2.1 to 3.5, p<0.001 for highest vs lowest third; 1.3, 1.2 to 1.7, p = 0.02 for middle vs lowest third), were independently associated with failed thrombolysis. Moreover, by multivariate Cox regression analysis according to tertiles of both cTnI (HR 1.2, 95% CI 1.1 to 1.8, p = 0.03 for highest vs middle third; 1.5, 1.2 to 2.2, p = 0.004 for highest vs lowest third; 1.1, 0.6 to 1.4, p = 0.6 for middle vs lowest third) and hs-CRP (HR1.2, 95% CI 1.1 to 1.6, p = 0.04 for highest vs middle third; 1.7, 1.3 to 2.6, p = 0.001 for highest vs lowest third; 1.1, 0.9 to 2.1, p = 0.1 for middle vs lowest third), were independently related with an increased risk of 30-day cardiac death. Conclusions: High circulating levels of both cTnI and hs-CRP are related with an independent increased risk of intravenous thrombolysis failure and 30-day cardiac death in patients who received intravenous thrombolysis in the first 6 h of STEMI.

The impact of aspirin resistance on the long-term cardiovascular mortality in patients with non-ST segment elevation acute coronary syndromes.

Aspirin resistance has been associated with an adverse long‐term outcome in patients with atherosclerotic coronary artery disease, but more studies are needed.

The Impact or Right Ventricular Involvement on the Postdischarge Long-Term Mortality in Patients With Acute Inferior ST-Segment Elevation Myocardial Infarction

Objectives: To investigate the long-term impact of right ventricular myocardial involvement (RVI) after acute inferior ST-segment elevation myocardial infarction (STEMI). Methods: A total of 1208 consecutive patients, who survived to discharge after hospitalization for acute inferior STEMI, were studied. Patients were divided into those with (n = 459) or without (n = 749) of RVI involvement, defined as ST-segment elevation ≥1 mm in V4R. Cardiac death by 3 years was the primary study end point. Results: By the end of follow-up, 207 (17.1%) patients had died. Patients with RVI were at similar risk for death at 3 years than those without (17.6% vs 16.8%, hazard ratio 1.1, 95% confidence interval 0.8-1.4, P = .79). By multivariate Cox analysis, several variables, but not RVI, were associated with the incidence of 3 years cardiac death. Conclusions: Right ventricular myocardial involvement does not portend any increased risk for long-term mortality, in patients who survived to discharge after hospitalization for acute inferior STEMI.

Effect of intravenous insulin administration on left ventricular performance during non-ST-elevation acute coronary events in patients with diabetes mellitus.

maintaining near-normal glycemia. 5 Group B patients were treated using the usual protocols, with oral hy- poglycemic drugs or 2 daily doses of intermediate- acting insulin. Supplementary small doses of short- acting insulin were administered subcutaneously only if glucose levels were 250 mg/dl. Mean daily plasma glucose levels were assessed in each patient in both groups by employing all the measured glucose values obtained during the study. The mean glucose level in the conservative treatment group was assessed by the 3 standard preprandial glucose values (at 7 A.M., 1 P.M., 6 P.M.), 1 measurement at 12 A.M. hours and any additional measurements that were performed accord- ing to the discretion of the attending physician. All patients were treated with an optimal antianginal reg- imen. Complete 2-dimensional, spectral, and color-fl ow Doppler echocardiographic examinations were per- formed by 2 examiners not involved in the fi nal anal- ysis of data, with a Hewlett-Packard Sonos 1000 Ul- trasound Machine (Andover, Massachusetts) with a 2.5-MHz transducer, while the patients were asymp- tomatic. Images were obtained within 3 hours from ad- mission and 72 hours later and stored on high-quality videotapes for later blinded analysis. A DI designed to determine the combined systolic and diastolic myocar- dial performance, and defi ned as the sum of isovolumet- ric contraction time plus isovolumetric relaxation time divided by ejection time, was estimated from LV outfl ow and mitral infl ow velocity patterns ((IVCT IVRT)/ ET).6 Videotape recordings were analyzed by 1 investi-

The influence of R-wave amplitude on the degree of ST-segment depression in exercise electrocardiography in the individual patient.

Many factors have been found to influence the magnitude of ST-segment depression in the exercise electrocardiogram. We investigated whether R-wave amplitude is a significant factor. We studied the exercise electrocardiogram of 20 patients with angiographically documented coronary artery disease, including ≥ 70% stenosis of the left anterior descending artery, who had an ischemic response to exercise but no previous anterior myocardial infarction. Precordial leads V1-6 were taken into account. When all 120 leads were measured, those with ST-segment depression ≥ 2.0mm at peak exercise had a mean resting R-wave amplitude of 19.03±5.81mm; those with ST-segment depression 2.0-1.0mm, R 11.42±5.99mm; and those with ST-segment depression < 1.0mm, R 5.9±5.21mm (p < 0.001 between groups). When the R-wave amplitude was correlated with the ST-segment depression in each precordial lead, the correlation was 1.0. In leads V1-6, when 67 tracings with ST-segment depression > 0.5mm were measured, the correlation was 0.537 (p < 0.001). In each precordial lead the t values of R-wave differences correlated very strongly (r < 0.883) with the differences in ST-segment depression. We conclude that precordial R-wave amplitude significantly influences the magnitude of ST-segment depression.

Serial snapshot electrocardiograms and continuous 12-lead ST-segment electrocardiographic monitoring for the prediction of intravenous thrombolysis outcome in patients with ST-segment elevation myocardial infarction

Abstract We compared the effectiveness of serial snapshot ECGs (S-ECG) and continuous 12-lead ST-segment ECG monitoring (C-ECG) for the prediction of intravenous thrombolysis outcome in 786 patients with ST-segment elevation myocardial infarction. It was found that S-ECG overestimated thrombolysis success over C-ECG by 7.1%. By 1-year patients who were diagnosed as having successful thrombolysis by S-ECG but not by C-ECG were at significantly higher risk of 1-year cardiac death than those who were classified as having successful thrombolysis by both ECG methods, and were at similar risk of 1-year cardiac death than those who were classified as having failed thrombolysis by both ECG methods.

Influence of biochemical markers on thrombolysis effectiveness early in the course of ST-segment elevation myocardial infarction

tiveness of monteplase admlnistration prior to emergent PCI in AMI. METHOD: Out of 243 consecutive AMI from 1998 to 2002. we enrolled into the COMA trial 108 patients who were under 75 years of age and had been admitted within 12 hrs after the onset of AMI. Patients were randomly assigned to receive direct PCI (group P, n=57) or PCI followed by pretreatment with intravenous monteplase (27500 IU/kg. group M, 1x51). RESULTS: Primary endpoint of this trial was left ventricular function (EF) at 6 months follow-up. In the initial CAG before PCI, TIMIflow was obtained in 29% of group M, but in only 7% of group P (P=O.O02). There was no significant difference in the PCI success rate, major cardiac or bleeding complications in both groups. No-reflow phenomenon in group P was obselved more frequently than group M (17.5% vs 4.4%. P=O.O4). There were no significant differences EF in both groups. Thus, we divided the group M into subgroups according to whether or not TIMIflow was obsewd at initial CAG. In the group M with TIMIflow, LVEDVI was smaller and the EF was greater than Group P (SS.O+/1.8 vs 5&6+/-l .4, P=O.O02). QCA results showed that the mlnimal lumen diameter was larger in the monteplase group M immediately after PCI, and the difference was even greater at 6 months. CONCLUSION: Intravenous Injection of monteplase can promote rapid repertusion and appears to maintain LV function, to suppress LV remodeling and late restenosis. We propose a combination therapy of PCI with monteplase injection in order to achieve reperfusion as early as possible,