Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of acute myocardial infarction, especially in young women without conventional cardiac risk factors. The role of intracoronary imaging in the assessment algorithm for SCAD is yet to be clearly defined, with a paucity of data on safety of use in this condition.

ugenia Nikolsky, MD, PHD,*† Eve D. Aymong, MD, FACC,*† Amir Halkin, MD,*† indy L. Grines, MD, FACC,‡ David A. Cox, MD, FACC,§ Eulogio Garcia, MD, oxana Mehran, MD, FACC,*† James E. Tcheng, MD, FACC,¶ John J. Griffin, MD, FACC,# iulio Guagliumi, MD,** Thomas Stuckey, MD, FACC,†† Mark Turco, MD, FACC,‡‡ avid A. Cohen, MD, FACC,§§ Manuela Negoita, MD,*† Alexandra J. Lansky, MD, FACC,*† regg W. Stone, MD, FACC*† ew York, New York; Royal Oak, Michigan; Charlotte, Durham, and Greensboro, North Carolina; Madrid, Spain; irginia Beach, Virginia; Bergamo, Italy; Tacoma Park, Maryland; and Boston, Massachusetts

Objective(s): Studies suggest that early revascularization following an AMI is equally important in both genders. We examined coronary revascularization (PCI or CABG) rates in men and women following an AMI. Methods: We studied a cohort of 7 728 patients >20 years with an AMI admission between January 1, 1999, and September 30, 2002 who underwent catheterization within 90 days of their index AMI. Demographic, clinical, and procedural data were obtained from the British Columbia (BC) Cardiac Registry, a prospective registry of all cardiac procedures performed in BC. Patients without 180 days of available follow-up and patients with a normal angiogram were excluded. Our primary objective was to examine gender differences in the odds of undergoing coronary revascularization within 180 days of the index coronary catheterization. We also examined time trends in revascularization rates by gender from 1999 to 2002. Results: Of the 6 726 eligible patients, 68.2% of women and 78.4% of men underwent revascularization within 180 days of their index catheterization following an AMI (p<0.0001). After adjusting for age, extent of vessel disease, hyperlipidemia, LVEF, DM, CHF, CRF, HTN, PVD, CVA, COPD, liver disease, cancer, case complexity, ICU/CCU use, and catheterization year, women were still less likely to undergo revascularization (OR 0.80, 95% CI 0.70 – 0.93). There was no interaction between gender and year of catheterization post-AMI (Figure 1 ). Conclusion: Conditional on receiving coronary catheterization within 90 days following an AMI, women were less likely to undergo coronary revascularization within 180 days compared to men. The gender difference persisted from 1999 to 2002.

Objectives We sought to determine the relationship between cigarette smoking and outcomes after mechanical reperfusion therapy in acute myocardial infarction (AMI).Background Prior studies have found that smokers with AMI have lower mortality rates and a more favorable response to fibrinolytic therapy than nonsmokers. The impact of cigarette smoking in patients undergoing primary percutaneous coronary intervention has not been examined.Methods In the CADILLAC trial, 2082 patients with AMI were randomized to percutaneous transluminal coronary angioplasty abciximab versus-stenting abciximab. Data on smoking status were prospectively collected and follow-up continued for 1 year.Results At the time of presentation, 638 (31%) patients had never smoked, 5,46 (26%) were former smokers, and 898 (45%) were currently smoking. In comparison to nonsmokers, current smokers were younger, more often men, and less frequently had diabetes, hypertension, prior AMI, and triple-vessel coronary disease. Procedural success rates were unrelated to smoking status. Mortality was lowest in current smokers, intermediate in former smokers, and highest in nonsmokers at 30 days (1.3% vs 1.7% vs 3.5%, respectively, P =.02) and 1 year (2.9% vs 3.7% vs 6.6%, P =.0008). After multivariate correction for differences in baseline variables, however, current smoking status was no longer protective from late mortality (hazard ratio 0.96, 95% Cl 0.52-1.76, P =.89).Conclusions The "smoker's paradox" extends to patients undergoing primary PCI for AMI, with increased survival seen in current smokers, an effect entirely explained by differences in baseline risk and not smoking status per se. The deleterious effects of smoking are expressed in the occurrence of AMI nearly a decade earlier than in nonsmokers, with similar age-adjusted risk, mandating intensive primary and secondary cigarette-cessation efforts.

OBJECTIVES We sought to determine the prognostic importance of mitral regurgitation (MR) in patients undergoing percutaneous coronary intervention for acute myocardial infarction (AMI).BACKGROUND Mitral regurgitation has been associated with a poor prognosis in patients treated with thrombolytic therapy for AMI. The prognostic significance of MR in patients undergoing mechanical reperfusion therapy for AMI is unknown.METHODS Left ventriculography was performed during the index procedure in 1,976 (95%) of 2,082 non-shock patients enrolled in a prospective, multicenter, randomized trial of mechanical reperfusion strategies in AMI. The severity of operator-assessed MR was divided into four strata: none (n = 1,726), mild (n = 192), and moderate/sevcre (n = 58).RESULTS. Patients with progressively more severe MR were older (p < 0.0001), were more often women (p < 0.0001), and had higher Killip class (p = 0.0007). More severe grades of MR correlated with triple-vessel disease (p < 0.0001) and lower left ventricular ejection fraction (LVEF) as measured during the index procedure (p = 0.0004). Increasingly severe MR was strongly associated with a higher mortality at 30 days (1.4% vs. 3.7% vs. 8.6%, respectively; p < 0.0001) and at one year (2.9%, 8.5%, 20.8%, respectively; p < 0.0001). By multivariate analysis, the presence of even mild MR was an independent predictor of long-term mortality (mild MR, relative risk [RR] = 2.40, p = 0.005; moderate/severe MR, RR = 2.82, p 0.006).CONCLUSIONS Mitral regurgitation of any degree present on the baseline left ventriculogram during the index procedure is a powerful, independent predictor of mortality in patients undergoing mechanical reperfusion therapy for AMI. The presence of MR identifies high-risk patients in whom close out-patient follow-up is warranted, and who may benefit from aggressive adjunctive medical or surgical therapies. (C) 2004by the American College of Cardiology Foundation

OBJECTIVES We sought to examine the effect of intravenous beta-blockers administered before primary percutaneous coronary intervention (PCI) on survival and myocardial recovery after acute myocardial infarction (AMI).BACKGROUND Studies of primary PCI but not thrombolysis have suggested that beta-blocker administration before reperfusion may enhance survival. Whether oral beta-blocker use before admission modulates this effect is unknown.METHODS The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial randomized 2,082 AMI patients to either stenting or balloon angioplasty, each +/- abciximab. In accordance with the protocol, intravenous beta-blockers were administered before PCI in the absence of contraindications.RESULTS A total of 1,136 patients (54.5%, BB+ group) received beta-blockers before PCI, whereas 946 (45.5%, BB- group) did not. The 30-day mortality was significantly lower in the BB+ group than in the BB- group (1.5% vs. 2.8%, p = 0.03), an effect entirely limited to patients who had not been receiving beta-blockers before admission (1.2% vs. 2.9%, p = 0.007). In contrast, no survival benefit with pre-procedural beta-blockers was observed in patients receiving beta-blockers at home (3.3% vs. 1.9%, respectively, p = 0.47). By multivariate analysis, pre-procedural beta-blocker use was an independent predictor of lower 30-day mortality among patients without previous beta-blocker therapy (relative risk = 0.38 [95% confidence interval 0.17 to 0.87], p = 0.02). The improvement in left ventricular ejection fraction from baseline to seven months was also greater after intravenous beta-blockers (3.8% vs. 1.3%, p = 0.01), an effect limited to patients not receiving oral beta-blockers before admission.CONCLUSIONS In patients with AMI undergoing primary PCI, myocardial recovery is enhanced and 30-day mortality is reduced with pre-procedural intravenous beta-blockade, effects confined to patients untreated with oral beta-blocker medication before admission. (C) 2004 by the American College of Cardiology Foundation.

Background Age is a strong independent predictor of outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Whether lower rates of reperfusion success contribute to the poor prognosis in elderly patients is unknown.Methods A formal ST-segment analysis substudy was performed in 695 patients undergoing primary PCI for AMI in the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. Reperfusion success (determined by the magnitude of ST-segment elevation resolution [STR] after PCI) was evaluated in 4 age groups: <50 years (n = 163), greater than or equal to50 to <60 years (n = 187), greater than or equal to60 to <70 years (n = 194), and greater than or equal to70 years (n = 151).Results There were no differences in the age groups for angiographic procedural success (>91% in all, P =.6), postprocedural Thrombolysis in Myocardial Infarction grade 3 flow (>94%, P =.8), and the proportions of patients with complete, partial, or absent STIR (P >.8). However, rates of 30-day mortality (0.6%, 1.1%, 3.6%, 6.0% respectively) and major adverse cardiac events (MACE; 2.5%, 4.8%, 6.2% 9.3%, respectively) increased with age. Rates of mortality and MACE were also inversely related to the magnitude of STR. Absent STIR (hazard ratio, 3.00; 95% Cl, 1.37-6.58; P=.006) and age (hazard ratio, 1.34; 95% Cl, 1.01-1.77; P =.04) were independent predictors of 30-day MACE by using multivariable modeling.Conclusions Lack of effective myocardial reperfusion is not a contributory mechanism responsible for the high morbidity and mortality rates observed in elderly patients. Nevertheless, advanced age and absent STR are both independent predictors of adverse outcomes after primary PCI, emphasizing the importance of successful reperfusion in the elderly population.

The purpose of this study was to examine the effect of vascular brachytherapy with gamma-radiation (gamma-RT) in patients with diabetes mellitus (DM) with coronary in-stent restenosis (ISR). In the Washington Radiation for In-Stent Restenosis (WRIST) trial, 130 patients with ISR were treated with (192)Ir or placebo. Of the patients enrolled, 44 (34%) had DM (18 of them treated with gamma-RT and 26 with placebo). Gamma-radiation therapy of ISR in diabetics resulted in similar procedural success and in-hospital outcome compared to nondiabetics. At 6-month follow-up, both DM and non-DM patients treated with gamma-RT had significantly lower target lesion revascularization (TLR), target vessel revascularization, and major adverse cardiac event rates compared to placebo. DM remains a powerful predictor of TLR and major adverse cardiac events even after treatment of ISR with gamma-RT.

The importance of sustained patency of the infarct-related artery after primary percutaneous coronary intervention for acute myocardial infarction is controversial. We examined serial measures of left ventricular function and clinical outcomes in 280 patients with an initially occluded infarct artery in whom Thrombolysis In Myocardial Infarction trial grade 3 flow was achieved and routine follow-up angiography was performed 7 months after percutaneous coronary intervention. Reocclusion of the infarct artery was associated with decreased event-free survival, and the degree of restenosis was an independent predictor of the lack in improvement in left ventricular ejection fraction over time.