Background— For patients with symptomatic New York Heart Association class III or IV, ejection fraction ≤35%, and QRS ≥130 ms, cardiac resynchronization therapy (CRT) has become an established treatment option. However, use of these implant criteria fails to result in clinical or echocardiographic improvement in 30% to 45% of CRT patients. Methods and Results— The Predictors of Response to CRT (PROSPECT)-ECG is a substudy of the prospective observational PROSPECT trial. ECGs collected before, during, and after CRT implantation were analyzed. Primary outcomes were improvement in clinical composite score (CCS) and reduction of left ventricular end systolic volume (LVESV) of >15% after 6 months. Age, sex, cause of cardiomyopathy, myocardial infarction location, right ventricular function, mitral regurgitation, preimplantation QRS width, preimplantation PR interval, preimplantation right ventricular–paced QRS width, preimplantation axis categories, LV-paced QRS width, postimplantation axis categories, difference between biventricular (Bi-V) pacing and preimplantation QRS width, and QRS bundle branch morphological features were analyzed univariably in logistic regression models to predict outcomes. All significant predictors (α=0.1), age, and sex were used for multivariable analyses. Cardiomyopathy cause interaction and subanalyses were also performed. In multivariable analyses, only QRS left bundle branch morphological features predicted both CCS (odds ratio [OR]=2.46, P =0.02) and LVESV (OR=2.89, P =0.048) response. The difference between Bi-V and preimplantation QRS width predicted CCS improvement (OR=0.89, P =0.04). LV-paced QRS width predicted LVESV reduction (OR=0.86, P =0.01). Specifically, an LV-paced QRS width of ≤200 ms was predictive of nonischemic LVESV reduction (OR=5.12, P =0.01). Conclusions— Baseline left bundle branch QRS morphological features, LV-paced QRS width, and the difference between Bi-V and preimplantation QRS width can predict positive outcomes after CRT and may represent a novel intraprocedural method to optimize coronary sinus lead placement. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00253357.

ObjectivesThe aim of this study was to determine the impact of delay to angioplasty in patients with acute coronary syndromes (ACS).BackgroundThere is a paucity of data on the impact of delays to percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) undergoing an invasive management strategy.MethodsPatients undergoing PCI in the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial were stratified according to timing of PCI after clinical presentation for outcome analysis.ResultsPercutaneous coronary intervention was performed in 7,749 patients (median age 63 years; 73% male) with NSTE-ACS at a median of 19.5 h after presentation (<8 h [n = 2,197], 8 to 24 h [n = 2,740], and >24 h [n = 2,812]). Delay to PCI >24 h after clinical presentation was significantly associated with increased 30-day mortality, myocardial infarction (MI), and composite ischemia (death, MI, and unplanned revascularization). By multivariable analysis, delay to PCI of >24 h was a significant independent predictor of 30-day and 1-year mortality. The incremental risk of death attributable to PCI delay >24 h was greatest in those patients presenting with high-risk features.ConclusionsIn this large-scale study, delaying revascularization with PCI >24 h in patients with NSTE-ACS was an independent predictor of early and late mortality and adverse ischemic outcomes. These findings suggest that urgent angiography and triage to revascularization should be a priority in NSTE-ACS patients. (J Am Coll Cardiol 2010; 55: 1416-24) (C) 2010 by the American College of Cardiology Foundation

AIMS:We sought to investigate the impact of multivessel coronary artery disease (CAD) on reperfusion success and prognosis following primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). The influence of multivessel disease on myocardial reperfusion and subsequent survival after primary PCI has not been studied.METHODS AND RESULTS:In the CADILLAC trial, primary PCI was performed in 2082 patients of any age with AMI within 12 h of symptom onset. Myocardial perfusion post-PCI assessed by ST-segment recovery and myocardial blush and clinical outcomes were stratified by the extent of CAD. Single-, double-, and triple-vessel disease were present in 1066 (51.2%), 692 (33.2%), and 324 (15.6%) patients, respectively. Patients with multivessel disease compared with those with single-vessel disease undergoing primary PCI were significantly more likely to have absent ST-segment recovery (13.3 vs. 7.4%, P = 0.01), though the rates of post-procedural TIMI-3 flow (89.7 vs. 88.9%, P = 0.66) and grade 2 or 3 myocardial blush (51.2 vs. 51.5%, P = 0.91) in the infarct vessel were comparable. By 1 year, the cumulative incidence of death for patients with single-, double-, and triple-vessel disease was 3.2, 4.4, and 7.8%, respectively (P = 0.003), and the composite rate of major adverse cardiac events (MACE) was 14.8, 19.5, and 23.6%, respectively (P = 0.0006). By multivariable analysis, the presence of triple-vessel disease was the strongest predictor of 1-year death [hazard ratio (HR) = 2.60, P = 0.009], death and re-infarction (HR = 1.88, P = 0.03), and MACE (HR = 1.80, P = 0.0009).CONCLUSION:Patients with extensive CAD in vessels remote from the infarct-related artery have reduced reperfusion success and an adverse prognosis following primary PCI in AMI. Future studies regarding the optimal treatment of patients with multivessel disease and AMI are warranted.

Sudden Cardiac Death (SCD) refers to death that occurs within 1 hour of the onset of symptoms.Because the majority of SCD occurs as an unwitnessed out-of-hospital event, data on the exact mechanisms are limited.However, in small series of patients who experienced SCD while wearing an ambulatory monitor 1,2 more than 80% of SCD episodes were noted to be due to ventricular tachyarrhythmias; therefore, SCD usually implies arrhythmic death and the terms are often used synonymously.SCD is among the leading causes of death in the developed world, including 350,000-400,000 cases annually in the United States. 3,4Prevention efforts are limited by the unpredictable onset of lethal arrhythmias and the rapid progression to death.Arrhythmia suppression with antiarrhythmic medications has proven ineffective and, in some cases, hazardous. 5Thus, current management strategies have two major components: aggressive treatment of the risk factors and cardiovascular conditions that predispose to SCD (e.g., hypertension, coronary heart disease, and heart failure); and in patients at high risk for arrhythmic death, the increasing use of implantable cardioverter defibrillators (ICDs).Although ICDs have proven to be powerful tools in both the primary 6-10 and secondary prevention of SCD, 11,12 identifying the patients who should receive an ICD remains a challenge.Current guidelines for ICD implantation include patients at the highest risk of SCD, but this represents only a minority of those who will have an event. 13Paradoxically, many of the patients who are covered by these guidelines will never experience SCD.This paradox is a reflection of the manner in which ICD indications have evolved.ICD indications are derived from randomized trials that,

Background The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial.Methods The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab.Results Earlier Earlier reperfusion (< 3 vs 3-6 vs > 6 hours) was associated with lower 1-year mortality (2.6% vs 4.3% vs 4.8%, P =.046 for < 3 vs >= 3 hours), more frequent grade 2 to.3 myocardial blush (55% vs 53% vs 44%, P =.003), more frequent complete ST-segment resolution (64% vs 68% vs 47%, P =.006), and greater improvement in left ventricular function. Early reperfusion (< 3 vs 3-6 vs >= 3 hours) was associated with lower mortality in high-risk patients (3.8% vs 6.9% vs 7.0%, P =.051 for < 3 vs >= 3 hours) but not in low-risk patients (1.4% vs 0.6% vs 1.0%, P =.63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms (<= 2 hours, hazard ratio 1.24, P =.013) but not late (> 2 hours, heart rate 0.88, P =.33).Conclusions Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.

OBJECTIVES We investigated the impact of diabetes mellitus on myocardial perfusion after primary percutaneous coronary intervention (PCI) utilizing myocardial blush grade (MBG) and ST-segment elevation resolution (STR).BACKGROUND Diabetes is an independent predictor of outcomes after primary PCI for acute myocardial infarction (AMI). Whether the poor prognosis is due to lower rates of myocardial reperfusion is unknown.METHODS Reperfusion success in those with and without diabetes mellitus was determined by measuring MBG (n = 1,301) and STR analysis (n = 700) in two substudies of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial among patients undergoing primary PCI for AMI.RESULTS There were no differences between those with or without diabetes with regard to postprocedural Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 (>95%), distribution of infarct-related artery, and the frequency of stent deployment or abciximab administration. Patients with diabetes mellitus were more likely to have absent myocardial perfusion (MBG 0/1, 56.0% vs. 47.1%, p = 0.01) and absent STR (20.3% vs. 8.1%, p = 0.002). Diabetes mellitus (hazard ratio [HR] 1.63 [95% confidence interval (CT) 1.17 to 2.28], p = 0.004) was an independent predictor of absent myocardial perfusion (MBG 0/1) and absent STR (HR 2.94 [95% CI 1.64 to 5.371, p = 0.005) by multivariate modeling.CONCLUSIONS Despite similar high rates of TIMI flow grade 3 after primary PCI in patients with and without diabetes, patients with diabetes are more likely to have abnormal myocardial perfusion as assessed by both incomplete STR and reduced MBG. Diminished microvascular perfusion in diabetics after primary PCI may contribute to adverse outcomes. (C) 2005 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.