The evolution of acute coronary syndromes (ACS) is not always clearly understood, and our understanding has been limited by the absence of serial information regarding the coronary vasculature in these patients. We describe a young patient with an acute inferior wall myocardial infarction in whom repeat multi-detector computed tomographic scanning (MDCT), supported by invasive studies, revealed a transient filling defect in the proximal left anterior descending coronary artery and nonobstructed circumflex and right coronary arteries. New generation 64-slice MDCT scanning provides a new method for visualizing both the coronary lumen and coronary plaque, and may prove to be a useful tool in improving our understanding of the dynamics of ACS.

Background The CURE study demonstrated the benefit of clopidogrel in patients with non-ST elevation (NSTE) acute coronary syndromes (ACSs), including those undergoing percutaneous coronary intervention (PCI). It did not report the relation between clopidogrel and timing of PCI or, more specifically, the role of clopidogrel in patients managed with an early interventional strategy, the current preferred treatment option for patients with NSTE ACSs. In the present study, we examined the relation between clopidogrel therapy, timing of PCI, and cardiovascular (CV) events in patients participating in the CURE study.Methods A total of 12562 patients with NSTE ACSs was randomized in double-blind fashion to clopidogrel or placebo (300 mg loading dose, then 75 mg/d) in addition to aspirin for up to 1 year. We analyzed the data of the 2658 CURE patients undergoing PCI and related the incidence of outcome events (CV death/myocardial infarction [MI]) to timing of PCI after randomization: early (<48 hours, median 1.0 day, n = 370), intermediate (>= 48 hours to initial hospital discharge, median 6.8 days, n = 1360), and late (after initial hospital discharge, median 47.6 days, n = 928).Results Clopidogrel showed consistent treatment benefit over the 12-month (mean 9 months) follow-up period irrespective of timing of PCI (relative risk [RR] 0.53 for the early group, RR 0.72 for the intermediate group, RR 0.70 for the late group). After adjustment for propensity to undergo PCI, the greatest treatment benefit of clopidogrel was observed in patients undergoing PCI <48 hours after randomization (RR 0.45, 95% CI 0.21-0.96, P =.038), although with overlap between groups. The lowest absolute event rate (6.7% CV death/MI) was observed in patients treated with clopidogrel and undergoing PCI within 48 hours. There was no increased risk of major bleeding in the early PCI group.Conclusions The benefit of therapy with clopidogrel in addition to aspirin in patients presenting with NSTE ACSs was significant irrespective of the timing of PCI. The combination of clopidogrel and an early (<48 hours) interventional strategy was associated with low absolute event rates for CV death/nonfatal MI.

OBJECTIVES The study examined differences in presentation and outcome between elderly ( greater than or equal to70 years) and very elderly ( greater than or equal to80 years) patients hospitalized for acute coronary syndromes (ACS).BACKGROUND The elderly constitute an increasingly important sector of patients with ACS but have been underrepresented in many therapeutic trials. METHODS We compiled a registry of 449 consecutive patients, 251 elderly (70 to 79 years) (septuagenarians, group 1) and 198 very elderly ( greater than or equal to80 years) (group 2), to examine outcomes in relation to baseline characteristics and treatment. We recorded survival over a period of 24 +/- 4 months and rehospitalization and symptomatic status at 16 +/- 4 months.RESULTS At index hospitalization, the older cohort (group 2) more often had acute myocardial infarction (35% vs. 9.7%, p < 0.0001), heart failure (33.3% vs. 19.4%, p < 0.001), and renal dysfunction (21.6% vs. 12.3%, p = 0.01). They were less likely to undergo coronary angiography (29.3% vs. 43.8%, p = 0.002), but those selected for angiography more often underwent revascularization so that revascularization rates were similar (22.7% group 2 vs. 24.3% group 1, p = NS). Two-year survival rate was poorer in group 2 (67.4 +/- 3.5% vs. 83.5 +/- 2.5% in group 1, p < 0.0001). Repeat rehospitalization was similar (53.0% vs. 48.2%, respectively, p = 0.31), but improvement in well-being of survivors was greater (60.0% vs. 46.3%, p = 0.01).CONCLUSIONS The study demonstrated important differences between elderly (70 to 79 years) and very elderly ( >= 80 years) patients hospitalized with ACS. The older cohort was sicker on admission and had poorer outcome, but a subgroup selected for angiography and possible intervention had two-year outcomes similar to the younger cohort. (c) 2004 by the American College of Cardiology Foundation.

Brachial artery endothelial function, which is measured as responsiveness to reactive hyperemia (flow-mediated dilation [FMD]) was abnormal in residents and house staff after a 24-hour shift, including night duty. The greatest decrease in FMD was observed in physicians with a longer history of night-shift duty and in those reporting fewer sleeping hours during the shift. The finding that FMD is decreased after night duty raises the issue of the effects of shift duty on cardiovascular function in healthcare personnel, particularly in those undertaking night duty for a prolonged period of time.

The Israel Resuscitation with Isoproterenol Study included 79 consecutive patients with witnessed out-of-hospital asystolic cardiac arrest who were resuscitated with epinephrine and atropine and randomized to receive additional isoproterenol or no isoproterenol. The rate of return of spontaneous circulation and survival to hospital admission did not differ in patients receiving standard therapy and those receiving additional isoproterenol.

The study examined outcomes in. a registry of 449 elderly patients; greater than or equal to 70 years) hospitalized for acute coronary syndromes. Outcomes were examined in relation to baseline characteristics and treatment options. Patients selected for coronary angiography and subsequent revascularization (RV) were more likely to be male (71.7%, p<0.001). In contrast, 52% of medically treated were male. Patients selected for RV were more likely to have suffered an acute MI (35.8% vs 26.2%, p=0.055), have had previous percutaneous coronary intervention (22.6% vs 13.2%, p=0.02) but less likely to have heart failure on admission (17.1% vs 28.2% of medically treated, p=0.02). Patients in their eighth and ninth decades were equally as likely to undergo RV. Two thirds (67.8%) of patients undergoing RV experienced symptomatic improvement at 16 months follow-tip vs 46.5% of patients treated medically (p=0.001). Two year survival rate was 82.3% for patients selected for RV and 75.3% for those treated medically (log rank p=0.18).

Sir—We read with interest the HERO- 2 informed consent substudy,1Williams BF French JK White HD for the HERO-2 consent substudy investigatorsInformed consent during the clinical emergency of acute myocardial infarction (HERO-2 consent substudy): a prospective observational study.Lancet. 2003; 361: 918-922Summary Full Text Full Text PDF PubMed Scopus (112) Google Scholar which highlights issues about the true essence of informed consent and some of the difficulties in applying ethical standards to ensure optimum patients' rights while undertaking necessary or essential medical research. The issues have not been satisfactorily resolved in the circumstances of an emergency medical situation, for which time to treatment is of utmost importance.2Boisjolie CR Sharkey SW Cannon CP et al.Impact of a thrombolysis research trial on time to treatment for acute myocardial infarction in the emergency department.Am J Cardiol. 1995; 76: 396-398Summary Full Text PDF PubMed Scopus (12) Google Scholar, 3De Luca SA Korcuska LA Oberstar BH Rosenthal ML Welsh PA Topol EJ Are we promoting true informed consent in cardiovascular clinical trials?.J Cardiovasc Nurs. 1995; 9: 54-61Crossref Scopus (29) Google Scholar The report by Williams and colleagues1Williams BF French JK White HD for the HERO-2 consent substudy investigatorsInformed consent during the clinical emergency of acute myocardial infarction (HERO-2 consent substudy): a prospective observational study.Lancet. 2003; 361: 918-922Summary Full Text Full Text PDF PubMed Scopus (112) Google Scholar points out inherent problems faced by a system burdened by lengthy and wordy documents laced with legal jargon, which is certainly unintelligible to many patients who present in the acute medical situation.In a similar study done in 150 patients in relation to the fourth international study of infarct survival (ISIS-4),4Yuval R Halon DA Merdler A et al.Patient comprehension and reaction to participating in a double-blind randomized clinical trial (ISIS-4) in acute myocardial infarction.Arch Intern Med. 2000; 160: 1142-1146Crossref PubMed Scopus (72) Google Scholar we recorded that only 40 (31%) of 129 patients perceived they had full comprehension of the trial, while 25 (19%) believed they had no understanding at all. 64 (43%) patients consenting to participate did so in the hope of better treatment, 53 (35%) to advance medical research, but very disturbingly 12 (8%) signed the informed consent form because they feared to refuse.By comparison of these data with those gathered in the circumstances of a non-acute situation (chronic heart failure trials with ample time for consideration, deliberation, and dialogue), we were surprised to note a strikingly similar pattern of perceived patients' understanding, no better than in the acute situation.5Yuval R Halon DA Flugelman MY Lewis BS Perceived patient comprehension in acute and chronic cardiovascular clinical trials.Cardiology. 2003; 99: 68-71Crossref PubMed Scopus (4) Google Scholar Moreover, 63% (71/112) of acute and 51% (32/63) of chronic patients recalled only an oral explanation of the trial, choosing to forget written explanations. These data suggest that human nature could be a major determinant of perceived comprehension. Irrespective of urgency (and of level of education in our study), a certain and similar proportion of patients always believe they comprehend and recall very well the explanations given by the health-care team. However, many patients prefer not to be involved in medical decisionmaking, and consciously or subconsciously recollect less well the processes at the time of consent and recruitment to the trial.We support the plea for a simpler, more intelligible, and perhaps more creative approach. We might need a strategy tailored in accord with a patient's profile, personality, and culture, and to the specific medical situation. It would be useful to establish a concerted multinational effort spearheaded by clinical-trial and ethics experts, working in collaboration with liberal and creative legal backing. Sir—We read with interest the HERO- 2 informed consent substudy,1Williams BF French JK White HD for the HERO-2 consent substudy investigatorsInformed consent during the clinical emergency of acute myocardial infarction (HERO-2 consent substudy): a prospective observational study.Lancet. 2003; 361: 918-922Summary Full Text Full Text PDF PubMed Scopus (112) Google Scholar which highlights issues about the true essence of informed consent and some of the difficulties in applying ethical standards to ensure optimum patients' rights while undertaking necessary or essential medical research. The issues have not been satisfactorily resolved in the circumstances of an emergency medical situation, for which time to treatment is of utmost importance.2Boisjolie CR Sharkey SW Cannon CP et al.Impact of a thrombolysis research trial on time to treatment for acute myocardial infarction in the emergency department.Am J Cardiol. 1995; 76: 396-398Summary Full Text PDF PubMed Scopus (12) Google Scholar, 3De Luca SA Korcuska LA Oberstar BH Rosenthal ML Welsh PA Topol EJ Are we promoting true informed consent in cardiovascular clinical trials?.J Cardiovasc Nurs. 1995; 9: 54-61Crossref Scopus (29) Google Scholar The report by Williams and colleagues1Williams BF French JK White HD for the HERO-2 consent substudy investigatorsInformed consent during the clinical emergency of acute myocardial infarction (HERO-2 consent substudy): a prospective observational study.Lancet. 2003; 361: 918-922Summary Full Text Full Text PDF PubMed Scopus (112) Google Scholar points out inherent problems faced by a system burdened by lengthy and wordy documents laced with legal jargon, which is certainly unintelligible to many patients who present in the acute medical situation. In a similar study done in 150 patients in relation to the fourth international study of infarct survival (ISIS-4),4Yuval R Halon DA Merdler A et al.Patient comprehension and reaction to participating in a double-blind randomized clinical trial (ISIS-4) in acute myocardial infarction.Arch Intern Med. 2000; 160: 1142-1146Crossref PubMed Scopus (72) Google Scholar we recorded that only 40 (31%) of 129 patients perceived they had full comprehension of the trial, while 25 (19%) believed they had no understanding at all. 64 (43%) patients consenting to participate did so in the hope of better treatment, 53 (35%) to advance medical research, but very disturbingly 12 (8%) signed the informed consent form because they feared to refuse. By comparison of these data with those gathered in the circumstances of a non-acute situation (chronic heart failure trials with ample time for consideration, deliberation, and dialogue), we were surprised to note a strikingly similar pattern of perceived patients' understanding, no better than in the acute situation.5Yuval R Halon DA Flugelman MY Lewis BS Perceived patient comprehension in acute and chronic cardiovascular clinical trials.Cardiology. 2003; 99: 68-71Crossref PubMed Scopus (4) Google Scholar Moreover, 63% (71/112) of acute and 51% (32/63) of chronic patients recalled only an oral explanation of the trial, choosing to forget written explanations. These data suggest that human nature could be a major determinant of perceived comprehension. Irrespective of urgency (and of level of education in our study), a certain and similar proportion of patients always believe they comprehend and recall very well the explanations given by the health-care team. However, many patients prefer not to be involved in medical decisionmaking, and consciously or subconsciously recollect less well the processes at the time of consent and recruitment to the trial. We support the plea for a simpler, more intelligible, and perhaps more creative approach. We might need a strategy tailored in accord with a patient's profile, personality, and culture, and to the specific medical situation. It would be useful to establish a concerted multinational effort spearheaded by clinical-trial and ethics experts, working in collaboration with liberal and creative legal backing.

Objective: We prospectively examined the prevalence of reversible perfusion defects on very early (12–24 h) thallium-201 single photon emission computed tomography (SPECT) scintigraphy after angiographically successful percutaneous coronary intervention (PCI) by stenting and/or stand-alone balloon angioplasty and the predictive value of these defects for late target lesion revascularization (TLR). Patients and Methods: 83 consecutive patients undergoing PCI for 88 lesions (38 balloon angioplasties, 50 stents) underwent very early (12–24 h) SPECT thallium-201 scintigraphy at rest and following administration of 0.7 mg/kg intravenous dipyridamole after PCI. Univariate and multivariate clinical, procedural and scintigraphic correlates of target lesion revascularization during long-term follow-up were examined. Results: Coronary stenting achieved a larger immediate post-PCI minimal luminal dimension (2.7 ± 0.4 vs. 2.1 ± 0.4 mm, p < 0.001) and less residual stenosis (4 ± 12 vs. 19 ± 11%, p < 0.001) than stand-alone balloon angioplasty. Nonetheless, early reversible perfusion defects were similarly present in the territory supplied by 36% of stented lesions and 32% of lesions treated by balloon angioplasty (NS). Of 81 lesions (76 patients) available for long-term clinical follow-up, TLR was performed in 11% of the stent group and 14% of the balloon angioplasty group (NS). By multivariate logistic regression analysis, diabetes mellitus was the only predictor of late TLR (p < 0.05). The type of intervention (balloon or stent) predicted neither early perfusion defects nor late TLR. Conclusions: Early 201-thallium SPECT scintigraphy was abnormal in a third of patients treated by stand-alone balloon angioplasty or by stent placement. The very early SPECT scintigraphic findings did not differentiate between balloon and stent and did not predict late TLR.