Circulation. 2008;118:2667-2668
doi: 10.1161/CIRCULATIONAHA.108.191131
(Circulation. 2008;118:2667-2668.)
© 2008 American Heart Association, Inc.
Clinical Summaries
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Irrigated Radiofrequency Catheter Ablation Guided by Electroanatomic Mapping for Recurrent Ventricular Tachycardia After Myocardial Infarction: The Multicenter Thermocool Ventricular Tachycardia Ablation Trial
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Although implantable cardioverter-defibrillators reduce death
resulting from ventricular tachycardia (VT), episodes of VT
decrease quality of life and predict increased rates of death.
Antiarrhythmic drugs are often used to suppress VT but have
potential adverse effects and relatively poor efficacy. In the
largest study to date of catheter ablation for recurrent monomorphic
VT caused by coronary artery disease, we prospectively evaluated
radiofrequency catheter ablation using an irrigated catheter
combined with an electroanatomic mapping system to facilitate
substrate mapping during sinus rhythm. In contrast to prior
studies, patients with hemodynamically unstable, unmappable
VTs and multiple VTs were included because these VTs are often
present in patients with ICDs. Despite a population with severely
depressed ventricular function and drug-refractory, frequent
VT, ablation abolished recurrent VT in approximately half of
the patients. Of those in whom VT recurred, the frequency of
episodes was substantially reduced for many, allowing reduction
or withdrawal of antiarrhythmic drugs for some patients. The
procedure mortality rate was 3%, and there were no strokes.
The 1-year mortality rate was 18%, with ventricular arrhythmias
and heart failure accounting for >70% of deaths. The present
study demonstrates that patients with recurrent sustained VT
and coronary artery disease are a high-risk population with
substantial death risk despite implantable cardioverter-defibrillators.
Catheter ablation is a reasonable option to reduce VT episodes,
even if multiple and unmappable VTs are present. See p
2773.
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Changes in Hospital Mortality Rates in 425 Patients With Acute ST-Elevation Myocardial Infarction and Cardiac Rupture Over a 30-Year Period
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The incidence of cardiac rupture and its rate of death were
investigated in 6678 consecutive ST-elevation myocardial infarction
patients during a 30-year period (1977 to 2006). A total of
425 patients experienced a free wall or septal rupture. After
the exclusion of referrals from other centers (n=44), the incidence
of definite cardiac rupture declined progressively (6.2% in
1977 to 1982 to 3.2% in 2001 to 2006) in parallel with a progressive
use of reperfusion therapy (0% to 75.1%). In addition, among
patients with cardiac rupture, there was a progressive fall
in mortality rates (94% to 75%) in conjunction with a better
control of systolic blood pressure; an increased use of reperfusion
therapy (0% to 59%), β-blockers (0% to 45%), angiotensin-converting
enzyme inhibitors (0% to 38%), and aspirin (0% to 96%); and
a lower use of heparin (99% to 67%). Although cardiac rupture
continues to be a frequent cause of death in ST-elevation myocardial
infarction patients in the reperfusion era, our findings disclose
that its incidence and rate of death have declined over the
last 30 years. Although we recognized that the origin of this
improvement is multifactorial, it is likely that it was associated
in part with the progressive use of reperfusion therapy, particularly
mechanical, and β-blockers, angiotensin-converting enzyme
inhibitors, and aspirin. Thus, our results further stress the
need for early implementation of these therapeutic measures
that may potentially prevent mechanical complications, particularly
in high-risk patients such as those with a first ST-elevation
myocardial infarction, >60 years of age, without overt heart
failure, and without ST-segment resolution. See p
2783.
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Prevalence, Prognosis, and Implications of Isolated Minor Nonspecific ST-Segment and T-Wave Abnormalities in Older Adults: Cardiovascular Health Study
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The prevalence and clinical significance of isolated minor nonspecific
ST-segment and T-wave abnormalities (NSSTTAs; characterized
by minor or upsloping ST-segment depression or T-wave flattening
or inversion <1.0 mm) are poorly characterized in older adults.
In the Cardiovascular Health Study, we observed that the prevalence
of isolated NSSTTAs was 7.2% among those
65 years of age without
major ECG abnormalities. The presence of isolated NSSTTAs was
significantly associated with risk for all-cause mortality and
especially coronary mortality (with nearly double the risk)
but not nonfatal myocardial infarction. The association was
independent of measures of subclinical atherosclerosis burden
and left ventricular mass. In secondary analyses, isolated NSSTTAs
appeared to be most strongly associated with primary arrhythmic
death, suggesting that they may in part represent arrhythmogenic
substrate. Whereas ECGs are not currently recommended as a routine
screening measure, these data suggest that ECGs obtained for
any clinical reason in older adults should be examined carefully
for the presence of isolated NSSTTAs. More than 80% of coronary
deaths occur in adults >65 years of age. Thus, physicians
and patients could consider more intensive management of modifiable
risk factors in those with isolated NSSTTAs to prevent fatal
events. See p
2790.
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Diagnostic-Therapeutic Cascade Revisited: Coronary Angiography, Coronary Artery Bypass Graft Surgery, and Percutaneous Coronary Intervention in the Modern Era
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Wide variability exists in rates of coronary angiography, depending
on geographic location. Although there is a strong relationship
between rates of angiography and revascularization, the relationship
is different depending on revascularization modality. With the
geographic area as the unit of analysis, regression models indicate
that coronary artery bypass rates are much less closely related
to angiography rates than are percutaneous coronary intervention
rates. In addition, there is a suggestion of a threshold effect
for coronary artery bypass graft surgery in that areas with
the highest angiography rates do no more coronary artery bypass
graft surgeries than areas with more modest rates. Percutaneous
coronary intervention rates, however, increase even at the very
highest angiography rates. We conclude that, in very-high-rate
areas, little or no additional serious coronary anatomy amenable
to coronary artery bypass graft surgery is identified. Because
routine use of percutaneous coronary intervention provides a
known mortality and acute myocardial infarction prevention benefit
only in patients with unstable coronary syndromes and because
patients with unstable symptoms are likely to reach the catheterization
laboratory no matter where they live, we are concerned that
patients with a lower chance to benefit may be undergoing percutaneous
coronary intervention in these areas of very high catheterization
rates. See p
2797.
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Sex Differences in Medical Care and Early Death After Acute Myocardial Infarction
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Women receive less evidence-based medical care than men and
had higher rates of death after acute myocardial infarction
(AMI). It is unclear whether efforts undertaken to improve AMI
care have mitigated these sex disparities in the current era.
We therefore examined sex differences in care processes and
in-hospital death among 78 254 patients with AMI from the Get
With the Guidelines–Coronary Artery Disease database in
420 US hospitals from 2001 to 2006. Women were older, had more
comorbidities, less often presented with ST-elevation myocardial
infarction, and had higher unadjusted in-hospital mortality
rates (8.2% versus 5.7%;
P<0.0001) than men. After adjustment
for baseline risk and clinical characteristics, sex-based differences
in rates of death early after AMI were no longer observed overall
but remained apparent in the ST-elevation myocardial infarction
subpopulation (10.2% versus 5.5%;
P<0.0001; adjusted odds
ratio=1.12; 95% CI, 1.02 to 1.23) and were possibly accounted
for by excess death among women in the initial 24 hours of hospitalization.
Compared with men, women were also less likely to receive early
aspirin and β-blocker treatments or reperfusion therapy
or to achieve timely reperfusion. Women also experienced lower
use of cardiac catheterization and revascularization procedures
after AMI. This report confirms the notion that women still
sustain higher adjusted mortality rates after ST-elevation myocardial
infarction compared with men. Evidence of lower use of guidelines-based
treatments and delayed reperfusion highlights the existing opportunities
to improve the provision of healthcare among women hospitalized
with AMI. Special attention should be given to those at highest
risk, especially women with ST-elevation myocardial infarction
during their early hospitalization period. See p
2803.
Related Articles:
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Prevalence, Prognosis, and Implications of Isolated Minor Nonspecific ST-Segment and T-Wave Abnormalities in Older Adults: Cardiovascular Health Study
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Changes in Hospital Mortality Rates in 425 Patients With Acute ST-Elevation Myocardial Infarction and Cardiac Rupture Over a 30-Year Period
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Irrigated Radiofrequency Catheter Ablation Guided by Electroanatomic Mapping for Recurrent Ventricular Tachycardia After Myocardial Infarction: The Multicenter Thermocool Ventricular Tachycardia Ablation Trial
- William G. Stevenson, David J. Wilber, Andrea Natale, Warren M. Jackman, Francis E. Marchlinski, Timothy Talbert, Mario D. Gonzalez, Seth J. Worley, Emile G. Daoud, Chun Hwang, Claudio Schuger, Thomas E. Bump, Mohammad Jazayeri, Gery F. Tomassoni, Harry A. Kopelman, Kyoko Soejima, Hiroshi Nakagawa for the Multicenter Thermocool VT Ablation Trial Investigators
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Diagnostic-Therapeutic Cascade Revisited: Coronary Angiography, Coronary Artery Bypass Graft Surgery, and Percutaneous Coronary Intervention in the Modern Era
- F.L. Lucas, A.E. Siewers, D.J. Malenka, and D.E. Wennberg
Circulation 2008 118: 2797-2802.
[Abstract]
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Sex Differences in Medical Care and Early Death After Acute Myocardial Infarction
- Hani Jneid, Gregg C. Fonarow, Christopher P. Cannon, Adrian F. Hernandez, Igor F. Palacios, Andrew O. Maree, Quinn Wells, Biykem Bozkurt, Kenneth A. LaBresh, Li Liang, Yuling Hong, L. Kristin Newby, Gerald Fletcher, Eric Peterson, Laura Wexler for the Get With the Guidelines Steering Committee and Investigators
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