Judith S Hochman, M.D.

International variation in and factors associated with hospital readmission after myocardial infarction
Kociol, Robb D; Lopes, Renato D; Clare, Robert; Thomas, Laine; Mehta, Rajendra H; Kaul, Padma; Pieper, Karen S; Hochman, Judith S; Weaver, W Douglas; Armstrong, Paul W; Granger, Christopher B; Patel, Manesh R
2012 Jan 4;307(1):66-74, JAMA
CONTEXT: ST-segment elevation myocardial infarction (STEMI) treatment has improved outcomes and shortened hospital stay. Recently, 30-day readmission rates have been proposed as a metric for care of patients with STEMI. However, international rates and predictors of 30-day readmission after STEMI have not been studied. OBJECTIVE: To determine international variation in and predictors of 30-day readmission rates after STEMI and country-level care patterns. DESIGN, SETTING, AND PATIENTS: Post hoc analysis of the Assessment of Pexelizumab in Acute Myocardial Infarction trial that enrolled 5745 patients with STEMI at 296 sites in the United States, Canada, Australia, New Zealand, and 13 European countries from July 13, 2004, to May 11, 2006. Multivariable logistic regression analysis was used to identify independent predictors of all-cause and nonelective 30-day postdischarge readmission. MAIN OUTCOME MEASURES: Predictors of 30-day postdischarge all-cause and nonelective readmissions. RESULTS: Of 5571 patients with STEMI who survived to hospital discharge, 631 (11.3%) were readmitted within 30 days. Thirty-day readmission rates were higher for the United States than other countries (14.5% vs 9.9%; P < .001). Median length of stay was shortest for US patients (3 days; interquartile range, 2-4 days) and longest for Germany (8 days; interquartile range, 6-11 days). In multivariable regression, the predictors of 30-day readmission included multivessel disease (odds ratio [OR], 1.97; 95% CI, 1.65-2.35) and US location (OR, 1.68; 95% CI, 1.37-2.07). Excluding elective readmission for revascularization, US enrollment was still an independent predictor of readmission (OR, 1.53; 95% CI, 1.20-1.96). After adjustment of the models for country-level median length of stay, US location was no longer an independent predictor of 30-day all-cause or nonelective readmission. Location in the United States was not a predictor of in-hospital death (OR, 0.88; 95% CI, 0.60-1.30) or 30-day postadmission death (OR, 1.0; 95% CI, 0.72-1.39). CONCLUSIONS: In this multinational study, there was variation across countries in 30-day readmission rates after STEMI, with readmission rates higher in the United States than in other countries. However, this difference was greatly attenuated after adjustment for length of stay
— id: 149984, year: 2012, vol: 307, page: 66, stat: Journal Article,

Effects of early and late re-infarction on mortality in patients with re-canalized or conservatively treated occluded coronary arteries in long term follow up of the Occluded Artery Trial (OAT)
Adlbrecht C.; Huber K.; Reynolds H.R.; Carvalho A.C.; White H.D.; Steg P.G.; Liu L.; Pearte C.A.; Marino P.; Hochman J.S.
2011 ;32:659-659, European heart journal
Background: The OAT trial demonstrated similar combined endpoint of death, re-infarction (Re-MI), and NYHA class IV heart failure either at 2.9 years mean or extended follow-up up to 9 years (n=2,201). OAT enrolled stable patients >24 hours (calendar days 3-28) post myocardial infarction (MI), with an angiographically confirmed occluded infarct-related artery (IRA). Patients were randomized either to receive percutaneous coronary intervention and optimal medical therapy (PCI), or to optimal medical therapy alone (MED). The study disclosed a trend towards more non-fatal Re-MIs in the PCI group, which was driven by excess type 4a or 4b MIs (i.e. PCI/stent-related) according to the universal MI definition. The current pre-specified analysis investigated the impact of Re-MIs, including time of occurrence (early (<=6 months) or late (>6 months) after randomization) and MI type on mortality. Methods: Cox regression models were used to analyze the effect of Re-MIs adjusted for baseline variables on mortality at a mean of 6 years of follow-up, and interaction with treatment assignment. Results: When the international universal definition of MI was applied, a total of 169 RE-MIs were detected (as compared to 142 Re-MIs based on the stricter MI criteria used in the OAT trial), of which 95 occurred in the PCI group and 74 in the MED group (p=0.08). After adjustment for baseline characteristics Re-MI patients had a 4.15-fold (95% CI 3.03-5.69, p<0.0001) increased risk of death compared to patients without Re-MI, whereby the risk was similar for both treatment groups (interaction p=0.26). Re-MI type 4a or 4b was associated with a similar impact on death (HR 3.29, 95% CI 1.80-6.02, p<0.0001) as spontaneous or secondary Re- MIs (i.e. MI types 1 or 2; HR 2.92, 95% CI 1.93-4.43, p<0.0001), (p=0.477 type 4a,b vs 1,2). Re-MIs occurring <=6 months after study entry (20/66 died) had similar impact on mortality as Re-MIs occurring >6 months after study entry (30/103 died) (p=0.60). Finally, there was no difference in the influence on mortality of Re-MIs by the qualifying IRA (HR 2.94, 95% CI 1.76-4.93, p<0.0001) or Re-MIs occurring in an epicardial coronary artery different from the IRA (HR 3.77, 95% CI 2.22-6.44, p<0.0001) (p=0.77 OAT IRA vs. nonIRA). Conclusions: For stable post-MI patients with totally occluded infarct arteries, the occurrence of a Re-MI had significant impact on mortality regardless of the initial management strategy (PCI vs. MED), early or late occurrence, location in the same or different IRA as the OAT qualifying MI and type of Re-MI based on the universal definition
— id: 137910, year: 2011, vol: 32, page: 659, stat: Journal Article,

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Anderson, Jeffrey L; Adams, Cynthia D; Antman, Elliott M; Bridges, Charles R; Califf, Robert M; Casey, Donald E Jr; Chavey, William E 2nd; Fesmire, Francis M; Hochman, Judith S; Levin, Thomas N; Lincoff, A Michael; Peterson, Eric D; Theroux, Pierre; Wenger, Nanette Kass; Wright, R Scott; Smith, Sidney C Jr
2011 May 10;123(18):e426-e579, Circulation
— id: 137098, year: 2011, vol: 123, page: e426, stat: Journal Article,

Loss of short-term symptomatic benefit in patients with an occluded infarct artery is unrelated to non-protocol revascularization: results from the Occluded Artery Trial (OAT)
Devlin, Gerard; Reynolds, Harmony R; Mark, Daniel B; Rankin, James M; Carvalho, Antonio C; Vozzi, Carlos; Sopko, George; Caramori, Paulo; Dzavik, Vladimir; Ragosta, Michael; Forman, Sandra A; Lamas, Gervasio A; Hochman, Judith S
2011 Jan;161(1):84-90, American heart journal
BACKGROUND: the OAT found that routine late (3-28 days post-myocardial infarction) percutaneous coronary intervention (PCI) of an occluded infarct-related artery did not reduce death, reinfarction, or heart failure relative to medical treatment (MED). Angina rates were lower in PCI early, but the advantage over MED was lost by 3 years. METHODS: angina and revascularization status were collected at 4 months, then annually. We assessed whether non-protocol revascularization procedures in MED accounted for loss of the early symptomatic advantage of PCI. RESULTS: seven per 100 more PCI patients were angina-free at 4 months (P < .001) and 5 per 100 at 12 months (P = .005) with the difference narrowing to 1 per 100 at 3 years (P = .34). Non-protocol revascularization was more frequent in MED (5-year rate 22% vs 19% PCI, P = .05). Indications for revascularization included acute coronary syndromes (39% PCI vs 38% MED), stable angina/inducible ischemia (39% in each group), and physician preference (17% PCI vs 15% MED). Revascularization rates among patients with angina at any time during follow-up (35% of cohort) did not differ by treatment group (5-year rates 26% PCI vs 28% MED). Most symptomatic patients were treated without revascularization during follow-up (77%). CONCLUSIONS: in a large randomized clinical trial of stable post-myocardial infarction patients, the modest benefit on angina from PCI of an occluded infarct-related artery was lost by 3 years. Revascularization was slightly more common in MED during follow-up but was not driven by acute ischemia, and almost 1 in 5 procedures were attributed to physician preference alone
— id: 137106, year: 2011, vol: 161, page: 84, stat: Journal Article,

Impact of National Clinical Guideline Recommendations for Revascularization of Persistently Occluded Infarct-Related Arteries on Clinical Practice in the United States
Deyell MW; Buller CE; Miller LH; Wang TY; Dai D; Lamas GA; Srinivas VS; Hochman JS
2011 Oct 10;171(18):1636-1643, Archives of internal medicine
BACKGROUND: The Occluded Artery Trial (OAT) was a large, randomized controlled trial published in 2006 that demonstrated no benefit to routine percutaneous coronary intervention (PCI) of persistently totally occluded infarct-related arteries (IRA) identified a minimum of 24 hours (on calendar days 3-28) after myocardial infarction (MI). The purpose of this study was to determine the impact of OAT results and consequent change in guideline recommendations for PCI for treatment of persistently occluded IRAs. METHODS: We identified all patients enrolled in the CathPCI Registry, from 2005 to 2008, undergoing catheterization more than 24 hours after MI with a totally occluded native coronary artery and no major OAT exclusion criteria. We examined trends in monthly rates of PCI for occlusions after OAT publication and after guideline revisions. Because reporting of diagnostic catheterizations was not mandatory, we examined trends among hospitals in the highest quartile for reporting of diagnostic procedures. RESULTS: A total of 28 780 patient visits from 896 hospitals were included. Overall, we found no significant decline in the adjusted monthly rate of PCI of occlusions after publication of OAT (odds ratio [OR], 0.997; 95% confidence interval [CI], 0.989-1.006) or after guideline revisions (OR, 1.007; 95% CI, 0.992-1.022). Among hospitals consistently reporting diagnostic catheterizations, there was no significant decline after OAT publication (OR, 1.018; 95% CI, 0.995-1.042), and there was a trend toward decline after guideline revisions (OR, 0.963; 95% CI, 0.920-1.000). CONCLUSION: These findings suggest that the results of OAT and consequent guideline revisions have not, to date, been fully incorporated into clinical practice in a large cross-section of hospitals in the United States
— id: 137096, year: 2011, vol: 171, page: 1636, stat: Journal Article,

Cardiogenic shock and heart failure post-percutaneous coronary intervention in ST-elevation myocardial infarction: observations from "Assessment of Pexelizumab in Acute Myocardial Infarction"
French, John K; Armstrong, Paul W; Cohen, Eric; Kleiman, Neal S; O'Connor, Christopher M; Hellkamp, Anne S; Stebbins, Amanda; Holmes, David R; Hochman, Judith S; Granger, Christopher B; Mahaffey, Kenneth W
2011 Jul;162(1):89-97, American heart journal
BACKGROUND: Mortality after ST-elevation myocardial infarction (STEMI) has reduced with reperfusion by primary percutaneous coronary intervention (PCI), which may have impacted on the adverse outcomes of cardiogenic shock (CS) and congestive heart failure (CHF). METHODS AND RESULTS: In the APEX-AMI trial, 5,745 patients with STEMI and planned primary PCI were randomly assigned pexelizumab or matching placebo. Post-randomization CS or CHF was adjudicated by a clinical endpoints committee. Treatment assignment to pexelizumab did not influence either endpoint or mortality rates. Cardiogenic shock developed in 196 patients (3.4%) at a median of 6.0 hours (interquartile range 3.9-28.3) post-randomization, and mortality at 90 days was 54.6%. Congestive heart failure occurred in 254 of patients (4.4%) at a median of 2.6 days (IQR 1.0-16.6), and mortality through 90 days was 10.2%; mortality among those with neither endpoint was 2.1%. Patients with CS or CHF were older, were more often female, and had more hypertension and diabetes, but smoked less compared with non-CS/CHF patients (all P < .05). Independent mortality predictors among those with CS or CHF were hyperlipidemia and a history of angina (interaction P = .011 and .008, respectively); procedural predictors among survivors to PCI were pre-PCI Thrombolysis In Myocardial Infarction (TIMI) flow 0-1 and post-PCI TIMI flow <3 (P = .013 and <.0001, respectively). CONCLUSIONS: Survival after CS remains poor despite aggressive reperfusion. Both CS and CHF remain the major causes of death among STEMI patients undergoing primary PCI. Future studies should examine treatments that aim to reduce mortality in these highest risk patients
— id: 137097, year: 2011, vol: 162, page: 89, stat: Journal Article,

2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines
Fuster, Valentin; Ryden, Lars E; Cannom, Davis S; Crijns, Harry J; Curtis, Anne B; Ellenbogen, Kenneth A; Halperin, Jonathan L; Kay, G Neal; Le Huezey, Jean-Yves; Lowe, James E; Olsson, S Bertil; Prystowsky, Eric N; Tamargo, Juan Luis; Wann, L Samuel; Smith, Sidney C Jr; Priori, Silvia G; Estes, N A Mark 3rd; Ezekowitz, Michael D; Jackman, Warren M; January, Craig T; Lowe, James E; Page, Richard L; Slotwiner, David J; Stevenson, William G; Tracy, Cynthia M; Jacobs, Alice K; Anderson, Jeffrey L; Albert, Nancy; Buller, Christopher E; Creager, Mark A; Ettinger, Steven M; Guyton, Robert A; Halperin, Jonathan L; Hochman, Judith S; Kushner, Frederick G; Ohman, Erik Magnus; Stevenson, William G; Tarkington, Lynn G; Yancy, Clyde W
2011 Mar 15;123(10):e269-e367, Circulation
— id: 137101, year: 2011, vol: 123, page: e269, stat: Journal Article,

Percutaneous coronary intervention for persistent occlusion of the infarct-related artery: An expanded view of the evidence - Reply [Note]
Hochman J.S.; Buller C.E.
2011 ;171(21):1961-1961, Archives of internal medicine
— id: 146273, year: 2011, vol: 171, page: 1961, stat: Journal Article,

Long-term effects of percutaneous coronary intervention of the totally occluded infarct-related artery in the subacute phase after myocardial infarction
Hochman, Judith S; Reynolds, Harmony R; Dzavik, Vladimir; Buller, Christopher E; Ruzyllo, Witold; Sadowski, Zygmunt P; Maggioni, Aldo P; Carvalho, Antonio C; Rankin, James M; White, Harvey D; Goldberg, Suzanne; Forman, Sandra A; Mark, Daniel B; Lamas, Gervasio A
2011 Nov 22;124(21):2320-2328, Circulation
BACKGROUND: Despite observations suggesting a benefit for late opening of totally occluded infarct-related arteries after myocardial infarction, the Occluded Artery Trial (OAT) demonstrated no reduction in the composite of death, reinfarction, and class IV heart failure over a 2.9-year mean follow-up. Follow-up was extended to determine whether late trends would favor either treatment group. METHODS AND RESULTS: OAT randomized 2201 stable patients with infarct-related artery total occlusion >24 hours (calendar days 3-28) after myocardial infarction. Patients with severe inducible ischemia, rest angina, class III-IV heart failure, and 3-vessel/left main disease were excluded. We conducted extended follow-up of enrolled patients for an additional 3 years for the primary end point and angina (6-year median survivor follow-up; longest, 9 years; 12 234 patient-years). Rates of the primary end point (hazard ratio, 1.06; 95% confidence interval, 0.88-1.28), fatal and nonfatal myocardial infarction (hazard ratio, 1.25; 95% confidence interval, 0.89-1.75), death, and class IV heart failure were similar for the percutaneous coronary intervention (PCI) and medical therapy alone groups. No interactions between baseline characteristics and treatment group on outcomes were observed. The vast majority of patients at each follow-up visit did not report angina. There was less angina in the PCI group through early in follow-up; by 3 years, the between group difference was consistently <4 patients per 100 treated and not significantly different, although there was a trend toward less angina in the PCI group at 3 and 5 years. The 7-year rate of PCI of the infarct-related artery during follow-up was 11.1% for the PCI group compared with 14.7% for the medical therapy alone group (hazard ratio, 0.79; 95% confidence interval, 0.61-1.01; P=0.06). CONCLUSIONS: Extended follow-up of the OAT cohort provides robust evidence for no reduction of long-term rates of clinical events after routine PCI in stable patients with a totally occluded infarct-related artery and without severe inducible ischemia in the subacute phase after myocardial infarction
— id: 148728, year: 2011, vol: 124, page: 2320, stat: Journal Article,

Early revascularization is beneficial across all ages and a wide spectrum of cardiogenic shock severity: A pooled analysis of trials
Jeger, Raban V; Urban, Philip; Harkness, Shannon M; Tseng, Chi-Hong; Stauffer, Jean-Christophe; Lejemtel, Thierry H; Sleeper, Lynn A; Pfisterer, Matthias E; Hochman, Judith S
2011 Mar;13(1):14-20, Acute Cardiac Care
BACKGROUND: A pooled analysis in cardiogenic shock due to acute coronary syndromes is desirable to assess the effect of early revascularization (ERV) across all ages and a wide spectrum of disease severity. METHODS: Only two randomized controlled trials (RCT), i.e. SMASH and SHOCK, met the inclusion criteria and were combined for a pooled analysis using individual patient data (n = 348). RESULTS: SMASH patients (n = 54, 16%) had more severe disease than SHOCK patients (n = 294, 84%). After adjustment for age, anoxic brain damage, non-inferior myocardial infarction, prior coronary artery bypass graft surgery, renal failure, systolic blood pressure, and selection for coronary angiography, one-year mortality was similar (relative risk SHOCK versus SMASH 0.87, 95% CI: 0.61-1.25). Relative risk of one-year death for ERV versus initial medical stabilization was 0.82 (95% CI: 0.70-0.96). There was no significant difference in the treatment effect by age (</=75 years relative risk at one year 0.79, 95% CI: 0.63-0.99; > 75 years relative risk at one year 0.93, 95% CI: 0.56-1.53; interaction P = 0.10). CONCLUSIONS: Only two RCT have been published emphasizing the difficulty of enrolling critically ill patients. Despite large differences in shock severity, ERV benefit is similar across all ages and not significantly different for the elderly
— id: 130295, year: 2011, vol: 13, page: 14, stat: Journal Article,

Genetic testing in patients with acute coronary syndromes to determine optimal anti-platelet strategy: A cost effective analysis
Lala A.; Sharma G.; Hochman J.S.; Berger J.S.; Braithwaite R.S.
2011 ;124(21 SUPPL 1):?-?, Circulation
Background: Prasugrel is effective at decreasing cardiovascular events compared to clopidogrel, but increases the risk of bleeding. In 2010, the FDA issued a black box warning to consider genetic testing in clopidogrel users. Our aims were to evaluate (1) the balance of potential benefits and harms and (2) the cost-effectiveness that would result from adopting a genotype-guided strategy of dual anti-platelet therapy following PCI for ACS vs. no testing strategies of prasugrel plus aspirin (prasugrel) or clopidogrel plus aspirin (clopidogrel). Methods: A Markov state transition model was used to conduct a decision analysis and compare strategies. Probabilities of adverse outcomes were derived from TRITON-TIMI 38 trial. Event rates on clopidogrel for carriers of CYP2C19*2 vs. wild-type were derived from the TRITON genetic substudy and a recent meta-analysis. Costs are expressed in January 2011 US dollars and estimated based on Medicare reimbursements for diagnosis-related group codes. Medication costs were used from the net wholesale price for prasugrel ($5.45/d) and a generic estimate for clopidogrel ($1/d). Results: In base case analyses, the genetic testing guided strategy yielded more benefits than harms, and was less costly compared to both 'no testing' strategies. Over 15 months, total costs were $83.8 ($1200.9 at 10 yrs) lower with a gain of 0.0007 QALY (0.0216 QALY at 10 yrs) in the genotype-guided strategy compared to prasugrel. Compared to clopidogrel, it was $0.38 ($2168.8 at 10 yrs) lower with a gain of 0.0036 QALY (0.112 QALY at 10 yrs). The strongest predictor of the preferred strategy was the relative risk (RR) of a thrombotic event occurring in CYP2C19*2 carriers versus wild-type. Below a RR of 1.5, a genotype-guided strategy is no longer more effective (but is less expensive) when compared to prasugrel. Compared to clopidogrel, below a RR of 1.3 a genotype-guided strategy is no longer cost effective (>$100,000/QALY). Clopidogrel costs ($1-$4/d) did not alter our results. Conclusions: Among ACS patients undergoing PCI, a genotype-guided strategy is economically favorable in determining which anti-platelet regimen is used, assuming that the risk of thrombotic events in CYP2C19*2 carriers is approximately 30-50% higher than wild type patients
— id: 147745, year: 2011, vol: 124, page: ?, stat: Journal Article,

Cardiovascular disease in young women: a population at risk
Levit, Rebecca D; Reynolds, Harmony R; Hochman, Judith S
2011 Mar-Apr;19(2):60-65, Cardiology in review
Ischemic heart disease (IHD) is a leading cause of morbidity in the United States and worldwide. In women, it is the leading cause of death in all age groups except young women who rarely have clinically evident disease. However, when young women less than age 50 develop IHD, they are at high risk for mortality. This may be due in part to delay in diagnosis or less aggressive treatment. Young women may be less aggressively treated with medical therapies and percutaneous or surgical interventions despite studies that have shown benefit in women as well as men. Young women are an especially important population to target for treatment and study since prevention of IHD during this stage of life can have great personal and societal health consequences. Epidemiological studies, including the INTERHEART study, have identified risk factors including hypertension, diabetes, metabolic syndrome, smoking, and sedentary lifestyle that explain much of IHD in women. Several factors, including diabetes, metabolic syndrome, and tobacco use, are stronger predictors of IHD in young women as compared with older women. Healthcare practitioners who encounter young women should aggressively treat risk factors, maintain an appropriate index of suspicion for IHD, and treat acute coronary syndromes promptly and intensively to reduce the burden of IHD in young women
— id: 122545, year: 2011, vol: 19, page: 60, stat: Journal Article,

The impact of postrandomization crossover of therapy in acute coronary syndromes care
Mahaffey, Kenneth W; Pieper, Karen S; Lokhnygina, Yuliya; Califf, Robert M; Antman, Elliott M; Kleiman, Neal S; Goodman, Shaun G; White, Harvey D; Rao, Sunil V; Hochman, Judith S; Cohen, Marc; Col, Jacques J; Roe, Matthew T; Ferguson, James J
2011 Mar 1;4(2):211-219, Ciculation : Cardiovascular quality & outcomes
BACKGROUND: In the Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) study, patients assigned enoxaparin or unfractionated heparin (UFH) were treated with alternative anticoagulant therapy after randomization at physician discretion, a practice made possible because the trial was open label. Using SYNERGY as an example, we demonstrate the difficulty of evaluating the effect of postrandomization events in clinical trials and discuss possible methodology. METHODS AND RESULTS: Patients with and without postrandomization crossovers were characterized and event rates analyzed. Statistical modeling was performed using inverse probability weighting and landmark analyses to evaluate the potential impact of postrandomization crossovers on event rates and treatment effect. Of 9978 SYNERGY patients, 9613 (96.3%) received at least 1 dose of randomized therapy and are included in these analyses. Of these, 740 (7.7%; 554 enoxaparin; 186 UFH) had postrandomization crossover. Crossover patients had higher unadjusted rates of 30-day death/myocardial infarction (MI) (18.9% versus 14.0%), thrombolysis in MI (TIMI) bleeding (16.9% versus 7.6%), Global Use of Strategies to Open Occluded Coronary Arteries bleeding (4.5% versus 2.3%), and transfusions (32.3% versus 15.2%). Adjustment for timing of crossover relative to the events attenuated the difference noted in death/MI but accentuated the association with TIMI bleeding. After adjustment using the inverse probability weighting technique, only a modest difference in the absolute treatment effect was observed between enoxaparin and UFH on death/MI (0.6% [unadjusted] versus 0.8% [adjusted]) and TIMI major bleeding (1.5% [unadjusted] versus 1.0% [adjusted]). The landmark analysis indicated a significant association between crossover from enoxaparin to UFH and TIMI bleeding but not in the other direction, and no crossover association was found in death/MI. CONCLUSIONS: Postrandomization events in clinical trials are accompanied by substantial confounders that require careful consideration. In SYNERGY, postrandomization crossovers occurred in nearly 10% of patients, abetted by the open-label trial design. These patients had increased incidence of bleeding and death/MI, but after adjustment using several modeling techniques, only a modest impact of postrandomization crossovers on treatment effect was observed. The usual methods of analyzing end points cannot adequately address biases in changing treatment in these patients. The potential biases of membership in a postrandomization subgroup, as well as the methods used to account for the biases, should be considered when weighing the strength of results. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00043784
— id: 134218, year: 2011, vol: 4, page: 211, stat: Journal Article,

Study design and rationale for the Stabilization of pLaques usIng Darapladib-Thrombolysis in Myocardial Infarction (SOLID-TIMI 52) trial in patients after an acute coronary syndrome
O'Donoghue, Michelle L.; Braunwald, Eugene; White, Harvey D.; Serruys, Patrick; Steg, Ph. Gabriel; Hochman, Judith; Maggioni, Aldo P.; Bode, Christoph; Weaver, Douglas; Johnson, Joel L.; Cicconetti, Greg; Lukas, Mary Ann; Tarka, Elizabeth; Cannon, Christopher P.
2011 OCT ;162(4):613-U62, American heart journal
Background Higher levels of lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) are associated with a higher risk of cardiovascular events and may play a causal role in atherogenesis. Darapladib inhibits Lp-PLA(2) activity in plasma and in arterial plaques and may confer clinical benefit in preventing cardiovascular events. Study Design The SOLID-TIMI 52 trial is a randomized, double-blind, placebo-controlled, multicenter, event-driven trial. Approximately 13,000 subjects are being randomized to darapladib (160 mg enteric-coated tablet daily) or matching placebo within 30 days of hospitalization with an acute coronary syndrome. The primary end point is the composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Secondary end points include major and total coronary events, individual components of the primary end point, and all-cause mortality. The study will continue until approximately 1,500 primary end point events have occurred to achieve 90% power to detect a 15.5% reduction in the primary end point. The median treatment duration is anticipated to be approximately 3 years, with a total study duration of approximately 4.1 years. Conclusions The SOLID-TIMI 52 trial will determine the clinical benefit of direct inhibition of Lp-PLA(2) activity with darapladib in patients after an acute coronary syndrome. (Am Heart J 2011;162:613-619.e1.)
— id: 140054, year: 2011, vol: 162, page: 613, stat: Journal Article,

Rapid complete reversal of systemic hypoperfusion after intra-aortic balloon pump counterpulsation and survival in cardiogenic shock complicating an acute myocardial infarction
Ramanathan, Krishnan; Farkouh, Michael E; Cosmi, John E; French, John K; Harkness, Shannon M; Dzavik, Vladimir; Sleeper, Lynn A; Hochman, Judith S
2011 Aug;162(2):268-275, American heart journal
BACKGROUND: In patients with cardiogenic shock (CS) complicating an acute myocardial infarction, a strategy of early revascularization (ERV) versus initial medical stabilization (IMS) improves survival. Intra-aortic balloon counterpulsation (IABC) provides hemodynamic support and facilitates coronary angiography and revascularization in CS patients. METHODS AND RESULTS: We evaluated 499 patients with record of systemic hypoperfusion status as an early response to IABC from the SHOCK trial (n = 185) and registry (n = 314) to determine the association between rapid complete reversal of systemic hypoperfusion (CRH) after 30 minutes of IABC and in-hospital, 30-day and 1-year mortality. Rapid complete reversal of systemic hypoperfusion was highly associated with lower in-hospital mortality (29% versus 65%, P < .001) in all patients. In the SHOCK trial, among patients assigned to ERV versus IMS, 30-day mortality was 26% versus 29%, respectively, with CRH and 61% versus 81%, respectively, without CRH after commencing IABC. The corresponding 1-year mortality rates were 35% versus 52% for ERV and 69% versus 87% for IMS (interaction P >/= .25 at both time points). After adjusting for important correlates of outcome (left ventricular ejection fraction, age, and randomization to ERV), a significant association remained between CRH and registry and trial in-hospital mortality (odds ratio 0.23, 95% CI 0.14-0.39, P < .001) and trial 1-year mortality (odds ratio .28, 95% CI 0.12-0.67, P < .001). CONCLUSIONS: In CS patients, CRH after commencing IABC was independently associated with improved in-hospital, 30-day and 1-year survival regardless of early revascularization. In CS patients, CRH with IABC is an important early prognostic feature
— id: 136643, year: 2011, vol: 162, page: 268, stat: Journal Article,

Mechanisms of Myocardial Infarction in Women Without Angiographically Obstructive Coronary Artery Disease
Reynolds HR; Srichai MB; Iqbal SN; Slater JN; Mancini GB; Feit F; Pena-Sing I; Axel L; Attubato MJ; Yatskar L; Kalhorn RT; Wood DA; Lobach IV; Hochman JS
2011 Sep 27;124(13):1414-1425, Circulation
BACKGROUND: . Unique identifier: NCT00798122
— id: 137093, year: 2011, vol: 124, page: 1414, stat: Journal Article,

Comparison of Late Results of Percutaneous Coronary Intervention Among Stable Patients </=65 Versus >65 Years of Age With an Occluded Infarct Related Artery (from the Occluded Artery Trial)
Skolnick AH; Reynolds HR; White HD; Menon V; Carvalho AC; Maggioni AP; Pearte CA; Gruberg L; Azevedo RE; Schroeder E; Forman SA; Lamas GA; Hochman JS; Dzavik V
2011 Dec 13;:?-? #, American journal of cardiology
Although opening an occluded infarct-related artery >24 hours after myocardial infarction in stable patients in the Occluded Artery Trial (OAT) did not reduce events over 7 years, there was a suggestion that the effect of treatment might differ by patient age. Baseline characteristics and outcomes by treatment with percutaneous coronary intervention (PCI) versus optimal medical therapy alone were compared by prespecified stratification at age 65 years. A p value <0.01 was prespecified as significant for OAT secondary analyses. The primary outcome was death, myocardial infarction, or New York Heart Association class IV heart failure. Patients aged >65 years (n = 641) were more likely to be female, to be nonsmokers, and to have hypertension, lower estimated glomerular filtration rates, and multivessel disease compared to younger patients (aged </=65 years, n = 1,560) (p <0.001). There was no significant observed interaction between treatment assignment and age for the primary outcome after adjustment (p = 0.10), and there was no difference between PCI and optimal medical therapy observed in either age group. At 7-year follow-up, younger patients tended to have angina more often compared to the older group (hazard ratio 1.21, 99% confidence interval 1.00 to 1.46, p = 0.01). The 7-year composite primary outcome was more common in older patients (p <0.001), and age remained significant after covariate adjustment (hazard ratio 1.42, 99% confidence interval 1.09 to 1.84). The rate of early PCI complications was low in the 2 age groups. The trend toward a differential effect of PCI in the young versus the old for the primary outcome was likely driven by measured and unmeasured confounders and by chance. PCI reduces angina to a similar degree in the young and old. In conclusion, there is no indication for routine PCI to open a persistently occluded infarct-related artery in stable patients after myocardial infarction, regardless of age
— id: 147671, year: 2011, vol: , page: ?, stat: Journal Article,

Women have less severe and extensive coronary atherosclerosis in fatal cases of ischemic heart disease: An autopsy study
Smilowitz, Nathaniel R; Sampson, Barbara A; Abrecht, Christopher R; Siegfried, Jonathan S; Hochman, Judith S; Reynolds, Harmony R
2011 Apr;161(4):681-688, American heart journal
OBJECTIVE: The study aims to evaluate sex differences in extent and severity of coronary artery disease (CAD) and myocardial findings at autopsy among young people with fatal ischemic heart disease (IHD). BACKGROUND: Women with acute coronary syndrome are less likely than men to display obstructive CAD at angiography. This suggests unique mechanisms of acute coronary syndrome exist in women or may reflect prehospital death of women with the most severe CAD. METHODS: Reports of autopsies by the Office of the Chief Medical Examiner of New York City on people aged 21 to 54 years who died between January 1, 2006, and December 31, 2008, were reviewed. A total of 639 cases of death due to atherosclerotic or arteriosclerotic cardiovascular disease according to the medical examiner were analyzed. Significant CAD was defined as >/=75% cross-sectional area stenosis in an epicardial vessel or >/=50% left main. RESULTS: Women were less likely to have obstructive CAD (63% vs 77% of men, P = .002). There was pathologic evidence of myocardial infarction (MI) in 43% of cases, 17% of which had nonobstructive CAD. Frequency of MI did not vary by sex overall (38% of women vs 45% of men, P = .18) or among those without significant CAD (23% vs 29%, P = .45). CONCLUSIONS: Among young people determined at autopsy to have died of IHD, fewer women had obstructive CAD, consistent with angiographic data in other IHD syndromes. Pathologic evidence of MI may exist in the absence of obstructive CAD
— id: 130911, year: 2011, vol: 161, page: 681, stat: Journal Article,

Reply to Letter Regarding Article, "The Impact of Collateral Flow to the Occluded Infarct-Related Artery on Clinical Outcomes in Patients With Recent Myocardial Infarction: A Report From the Randomized Occluded Artery Trial"
Steg, Ph Gabriel; Kerner, Arthur; Mancini, G. B. John; Buller, Christopher E.; Carvalho, Antonio C.; Forman, Sandra A.; Fridrich, Viliam; Reynolds, Harmony R.; Hochman, Judith S.; Lamas, Gervasio A.; White, Harvey D.
2011 MAR 1 ;123(8):E257-E258, Circulation
— id: 126457, year: 2011, vol: 123, page: E257, stat: Journal Article,

The Occluded Artery Trial (OAT) Viability Ancillary Study (OAT-NUC): influence of infarct zone viability on left ventricular remodeling after percutaneous coronary intervention versus optimal medical therapy alone
Udelson, James E; Pearte, Camille A; Kimmelstiel, Carey D; Kruk, Mariusz; Kufera, Joseph A; Forman, Sandra A; Teresinska, Anna; Bychowiec, Bartosz; Marin-Neto, Jose Antonio; Hochtl, Thomas; Cohen, Eric A; Caramori, Paulo; Busz-Papiez, Benita; Adlbrecht, Christopher; Sadowski, Zygmunt P; Ruzyllo, Witold; Kinan, Debra J; Lamas, Gervasio A; Hochman, Judith S
2011 Mar;161(3):611-621, American heart journal
BACKGROUND: The Occluded Artery Trial (OAT) showed no difference in outcomes between percutaneous coronary intervention (PCI) versus optimal medical therapy (MED) in patients with persistent total occlusion of the infarct-related artery 3 to 28 days post-myocardial infarction. Whether PCI may benefit a subset of patients with preservation of infarct zone (IZ) viability is unknown. METHODS AND RESULTS: The OAT nuclear ancillary study hypothesized that (1) IZ viability influences left ventricular (LV) remodeling and that (2) PCI as compared with MED attenuates adverse remodeling in post-myocardial infarction patients with preserved viability. Enrolled were 124 OAT patients who underwent resting nitroglycerin-enhanced technetium-99m sestamibi single-photon emission computed tomography (SPECT) before OAT randomization, with repeat imaging at 1 year. All images were quantitatively analyzed for infarct size, IZ viability, LV volumes, and function in a core laboratory. At baseline, mean infarct size was 26% +/- 18 of the LV, mean IZ viability was 43% +/- 8 of peak uptake, and most patients (70%) had at least moderately retained IZ viability. There were no significant differences in 1-year end-diastolic or end-systolic volume change between those with severely reduced versus moderately retained IZ viability, or when compared by treatment assignment PCI versus MED. In multivariable models, increasing baseline viability independently predicted improvement in ejection fraction (P = .005). There was no interaction between IZ viability and treatment assignment for any measure of LV remodeling. CONCLUSIONS: In the contemporary era of MED, PCI of the infarct-related artery compared with MED alone does not impact LV remodeling irrespective of IZ viability
— id: 133341, year: 2011, vol: 161, page: 611, stat: Journal Article,

2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran). A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Wann, L Samuel; Curtis, Anne B; Ellenbogen, Kenneth A; Estes, N A Mark 3rd; Ezekowitz, Michael D; Jackman, Warren M; January, Craig T; Lowe, James E; Page, Richard L; Slotwiner, David J; Stevenson, William G; Tracy, Cynthia M; Fuster, Valentin; Ryden, Lars E; Cannom, David S; Crijns, Harry J; Curtis, Anne B; Ellenbogen, Kenneth A; Halperin, Jonathan L; Kay, G Neal; Le Heuzey, Jean-Yves; Lowe, James E; Olsson, S Bertil; Prystowsky, Eric N; Tamargo, Juan Luis; Wann, L Samuel; Jacobs, Alice K; Anderson, Jeffrey L; Albert, Nancy; Creager, Mark A; Ettinger, Steven M; Guyton, Robert A; Halperin, Jonathan L; Hochman, Judith S; Kushner, Frederick G; Ohman, Erik Magnus; Stevenson, William G; Yancy, Clyde W
2011 Mar;8(3):e1-e8, Heart rhythm
— id: 137103, year: 2011, vol: 8, page: e1, stat: Journal Article,

2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on Dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines
Wann, L Samuel; Curtis, Anne B; Ellenbogen, Kenneth A; Estes, N A Mark 3rd; Ezekowitz, Michael D; Jackman, Warren M; January, Craig T; Lowe, James E; Page, Richard L; Slotwiner, David J; Stevenson, William G; Tracy, Cynthia M; Fuster, Valentin; Ryden, Lars E; Cannom, David S; Crijns, Harry J; Curtis, Anne B; Ellenbogen, Kenneth A; Halperin, Jonathan L; Kay, G Neal; Le Heuzey, Jean-Yves; Lowe, James E; Olsson, S Bertil; Prystowsky, Eric N; Tamargo, Juan Luis; Wann, L Samuel; Jacobs, Alice K; Anderson, Jeffrey L; Albert, Nancy; Creager, Mark A; Ettinger, Steven M; Guyton, Robert A; Halperin, Jonathan L; Hochman, Judith S; Kushner, Frederick G; Ohman, Erik Magnus; Stevenson, William G; Yancy, Clyde W
2011 Mar 15;123(10):1144-1150, Circulation
— id: 137102, year: 2011, vol: 123, page: 1144, stat: Journal Article,

2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Wann, L Samuel; Curtis, Anne B; January, Craig T; Ellenbogen, Kenneth A; Lowe, James E; Estes, N A Mark 3rd; Page, Richard L; Ezekowitz, Michael D; Slotwiner, David J; Jackman, Warren M; Stevenson, William G; Tracy, Cynthia M; Fuster, Valentin; Ryden, Lars E; Cannom, David S; Le Heuzey, Jean-Yves; Crijns, Harry J; Lowe, James E; Curtis, Anne B; Olsson, S Bertil; Ellenbogen, Kenneth A; Prystowsky, Eric N; Halperin, Jonathan L; Tamargo, Juan Luis; Kay, G Neal; Wann, L Samuel; Jacobs, Alice K; Anderson, Jeffrey L; Albert, Nancy; Hochman, Judith S; Buller, Christopher E; Kushner, Frederick G; Creager, Mark A; Ohman, Erik Magnus; Ettinger, Steven M; Stevenson, William G; Guyton, Robert A; Tarkington, Lynn G; Halperin, Jonathan L; Yancy, Clyde W
2011 Jan;8(1):157-176, Heart rhythm
— id: 137107, year: 2011, vol: 8, page: 157, stat: Journal Article,

2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Wann, L Samuel; Curtis, Anne B; January, Craig T; Ellenbogen, Kenneth A; Lowe, James E; Estes, N A Mark 3rd; Page, Richard L; Ezekowitz, Michael D; Slotwiner, David J; Jackman, Warren M; Stevenson, William G; Tracy, Cynthia M; Fuster, Valentin; Ryden, Lars E; Cannom, David S; Le Heuzey, Jean-Yves; Crijns, Harry J; Lowe, James E; Curtis, Anne B; Olsson, S Bertil; Ellenbogen, Kenneth A; Prystowsky, Eric N; Halperin, Jonathan L; Tamargo, Juan Luis; Kay, G Neal; Wann, L Samuel; Jacobs, Alice K; Anderson, Jeffrey L; Albert, Nancy; Hochman, Judith S; Buller, Christopher E; Kushner, Frederick G; Creager, Mark A; Ohman, Erik Magnus; Ettinger, Steven M; Stevenson, William G; Guyton, Robert A; Tarkington, Lynn G; Halperin, Jonathan L; Yancy, Clyde W
2011 Jan 4;123(1):104-123, Circulation
— id: 137105, year: 2011, vol: 123, page: 104, stat: Journal Article,

2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Wann, L Samuel; Curtis, Anne B; January, Craig T; Ellenbogen, Kenneth A; Lowe, James E; Estes, N A Mark 3rd; Page, Richard L; Ezekowitz, Michael D; Slotwiner, David J; Jackman, Warren M; Stevenson, William G; Tracy, Cynthia M; Fuster, Valentin; Ryden, Lars E; Cannom, David S; Le Heuzey, Jean-Yves; Crijns, Harry J; Lowe, James E; Curtis, Anne B; Olsson, S Bertil; Ellenbogen, Kenneth A; Prystowsky, Eric N; Halperin, Jonathan L; Tamargo, Juan Luis; Kay, G Neal; Wann, L Samuel; Jacobs, Alice K; Anderson, Jeffrey L; Albert, Nancy; Hochman, Judith S; Buller, Christopher E; Kushner, Frederick G; Creager, Mark A; Ohman, Erik Magnus; Ettinger, Steven M; Stevenson, William G; Guyton, Robert A; Tarkington, Lynn G; Halperin, Jonathan L; Yancy, Clyde W
2011 Jan 11;57(2):223-242, Journal of the American College of Cardiology
— id: 137104, year: 2011, vol: 57, page: 223, stat: Journal Article,

Predictors of reinfarction following PCI or medical management using the universal definition in patients with total occlusion after myocardial infarction: Results from OAT long term follow up
White H.D.; Reynolds H.R.; Carvalho A.C.; Liu L.; Pearte C.A.; Dzavik V.; Kruk M.; Steg P.G.; Lamas G.A.; Hochman J.S.
2011 ;32:738-739, European heart journal
Purpose: The Occluded Artery Trial (OAT) randomized 2201 patients with an occluded infarct-related artery on days 3-28 (>24 hours) following MI to either percutaneous coronary intervention (PCI) or medical treatment (MED). There was no difference in the primary endpoint of death, reinfarction (reMI) or heart failure either at 2.9 years (mean) or follow up to 9 years. However in patients randomized to PCI there was a trend for an increase in adjudicated reMI. This analysis sought to determine the independent predictors of reMI over mean 6 years follow up. Methods: reMIs were adjudicated blinded to randomization and according to the universal definition, for a type 1 (spontaneous) or type 2 Infarction (supplydemand mismatch) and after PCI (type 4), biomarkers 3x upper limit of normal (ULN) and after bypass surgery (type 5), biomarkers 5x ULN. Cox multivariable regression models were developed including baseline demographics and angiographic data, p<0.01 was considered significant. Results: There were 169 reMIs; (9.4% PCI vs. 8.0% MED, HR 1.31, 95% CI 0.97 - 1.77, p=0.08). The most common type of reMI was type 1 (62.7%) with no difference between the groups; 4.9% PCI vs 6.7% MED, HR 0.78, 95% CI 0.53 - 1.15, p=0.21. There were more type 4 reMIs in the PCI group; 3.5% vs 0.7%, HR 5.22, 95% CI 2.32 - 11.74, p<0.001, with an increase in type 4a reMI (related to protocol or repeat PCI); 0.8% PCI vs 0.1% MED, HR 9.03, 95% CI 1.14 - 71.3, p=0.01, and an increase in type 4b reMI (stent thrombosis); 2.7% PCI vs 0.6% MED, HR 4.59, 95% CI 1.89 - 11.1, p<0.001. Most reMIs in the PCI group were in the OAT qualifying territory (when assessed n=135); 59.5% vs 37.7% MED, p=0.01. There were 11/95 (11.6%) fatal reMIs in the PCI group and 8/74 (10.8%) in the MED group. Multivariate predictors of reMI for the overall group were: prior history of PCI, p=0.001, diabetes, p=0.005, and no new Q waves with the index infarction, p=0.011. There were no angiographic predictors of reMI. Among the PCI group multivariate predictors of reMI were prior history of MI, p=0.011, and lower ejection fraction, p=0.004. For the MED group the only predictor was a prior history of PCI, p=0.0001. Conclusions: There was a trend for more reMIs in patients randomized to PCI as compared with MED. There were significantly more type 4 reMIs in the PCI group largely driven by excess stent thrombosis. No modifiable predictors of reMI were identified. Opening an occluded infarct-related artery in stable patients late post MI creates a substrate exposing them to a risk of reMI related to reocclusion and stent thrombosis
— id: 137909, year: 2011, vol: 32, page: 738, stat: Journal Article,

2011 ACCF/AHA focused update of the Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction (updating the 2007 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
Wright, R Scott; Anderson, Jeffrey L; Adams, Cynthia D; Bridges, Charles R; Casey, Donald E Jr; Ettinger, Steven M; Fesmire, Francis M; Ganiats, Theodore G; Jneid, Hani; Lincoff, A Michael; Peterson, Eric D; Philippides, George J; Theroux, Pierre; Wenger, Nanette K; Zidar, James Patrick; Anderson, Jeffrey L; Adams, Cynthia D; Antman, Elliott M; Bridges, Charles R; Califf, Robert M; Casey, Donald E Jr; Chavey, William E 2nd; Fesmire, Francis M; Hochman, Judith S; Levin, Thomas N; Lincoff, A Michael; Peterson, Eric D; Theroux, Pierre; Wenger, Nanette K; Wright, R Scott
2011 May 10;57(19):1920-1959, Journal of the American College of Cardiology
— id: 137100, year: 2011, vol: 57, page: 1920, stat: Journal Article,

2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons
Wright, R Scott; Anderson, Jeffrey L; Adams, Cynthia D; Bridges, Charles R; Casey, Donald E Jr; Ettinger, Steven M; Fesmire, Francis M; Ganiats, Theodore G; Jneid, Hani; Lincoff, A Michael; Peterson, Eric D; Philippides, George J; Theroux, Pierre; Wenger, Nanette K; Zidar, James Patrick; Anderson, Jeffrey L; Adams, Cynthia D; Antman, Elliott M; Bridges, Charles R; Califf, Robert M; Casey, Donald E Jr; Chavey, William E 2nd; Fesmire, Francis M; Hochman, Judith S; Levin, Thomas N; Lincoff, A Michael; Peterson, Eric D; Theroux, Pierre; Wenger, Nanette Kass; Wright, R Scott
2011 May 10;57(19):e215-e367, Journal of the American College of Cardiology
— id: 137099, year: 2011, vol: 57, page: e215, stat: Journal Article,

A routine invasive strategy for out-of-hospital cardiac arrest survivors: are we there yet?
Bangalore, Sripal; Hochman, Judith S
2010 Jun 1;3(3):197-199, Circulation: Cardiovascular Interventions
— id: 112227, year: 2010, vol: 3, page: 197, stat: Journal Article,

Sex and race are associated with the absence of epicardial coronary artery obstructive disease at angiography in patients with acute coronary syndromes
Chokshi, Neel P; Iqbal, Sohah N; Berger, Rachel L; Hochman, Judith S; Feit, Frederick; Slater, James N; Pena-Sing, Ivan; Yatskar, Leonid; Keller, Norma M; Babaev, Anvar; Attubato, Michael J; Reynolds, Harmony R
2010 Aug;33(8):495-501, Clinical cardiology
BACKGROUND: A substantial minority of patients with acute coronary syndromes (ACS) do not have a diameter stenosis of any major epicardial coronary artery on angiography ('no obstruction at angiography') of >/= 50%. We examined the frequency of this finding and its relationship to race and sex. HYPOTHESIS: Among patients with myocardial infarction, younger age, female sex and non-white race are associated with the absence of obstructive coronary artery disease at angiography. METHODS: We reviewed the results of all angiograms performed from May 19, 2006 to September 29, 2006 at 1 private (n = 793) and 1 public (n = 578) urban academic medical center. Charts were reviewed for indication and results of angiography, and for demographics. RESULTS: The cohort included 518 patients with ACS. There was no obstruction at angiography in 106 patients (21%), including 48 (18%) of 258 patients with myocardial infarction. Women were more likely to have no obstruction at angiography than men, both in the overall cohort (55/170 women [32%] vs 51/348 men [15%], P < 0.001) and in the subset with MI (29/90 women [32%] vs 19/168 men [11%], P < 0.001). Black patients were more likely to have no obstruction at angiography relative to any other subgroup (24/66 [36%] vs 41/229 [18%] Whites, 31/150 [21%] Hispanics, and 5/58 [9%] Asians, P = 0.001). Among women, Black patients more frequently had no obstruction at angiography compared with other ethnic groups (16/27 [59%] vs 17/59 [29%] Whites, 17/60 [28%] Hispanics, and 3/19 [6%] Asians, P = 0.001). CONCLUSIONS: A high proportion of a multiethnic sample of patients with ACS were found to have no stenosis >/= 50% in diameter at coronary angiography. This was particularly common among women and Black patients.
— id: 111980, year: 2010, vol: 33, page: 495, stat: Journal Article,

Mechanical complications after percutaneous coronary intervention in ST-elevation myocardial infarction (from APEX-AMI)
French, John K; Hellkamp, Anne S; Armstrong, Paul W; Cohen, Eric; Kleiman, Neil S; O'Connor, Christopher M; Holmes, David R; Hochman, Judith S; Granger, Christopher B; Mahaffey, Kenneth W
2010 Jan 1;105(1):59-63, American journal of cardiology
A decrease in mechanical complications after ST-elevation myocardial infarction may have contributed to improved survival rates associated with reperfusion by primary percutaneous coronary intervention (PCI). Mechanical complications occurred in 52 of 5,745 patients (0.91%) in the largest reported randomized trial in which primary PCI was the reperfusion strategy. The frequencies were 0.52% (30) for cardiac free-wall rupture (tamponade), 0.17% (10) for ventricular septal rupture, and 0.26% (15) for papillary muscle rupture (3 patients had 2 complications). Ninety-day survival rates were 37% (11) for cardiac free-wall rupture, 20% (2) for ventricular septal rupture, and 73.3% (11) for papillary muscle rupture. These mechanical complications occurred at a median of 23.5 hours (interquartile range 5.0 to 76.8) after symptom onset and were associated with 44% (23 of 52) survival through 90 days, which accounted for 11% of the 90-day mortality. Factors associated with mechanical complications were older age, female gender, Q waves, presence of radiologic pulmonary edema, and increased prerandomization troponin levels. In conclusion, rates of mechanical complications are lower with primary PCI than those previously reported after fibrinolytic therapy
— id: 133448, year: 2010, vol: 105, page: 59, stat: Journal Article,

2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Greenland, Philip; Alpert, Joseph S; Beller, George A; Benjamin, Emelia J; Budoff, Matthew J; Fayad, Zahi A; Foster, Elyse; Hlatky, Mark A; Hodgson, John McB; Kushner, Frederick G; Lauer, Michael S; Shaw, Leslee J; Smith, Sidney C Jr; Taylor, Allen J; Weintraub, William S; Wenger, Nanette K; Jacobs, Alice K; Anderson, Jeffrey L; Albert, Nancy; Buller, Christopher E; Creager, Mark A; Ettinger, Steven M; Guyton, Robert A; Halperin, Jonathan L; Hochman, Judith S; Kushner, Frederick G; Nishimura, Rick; Ohman, E Magnus; Page, Richard L; Stevenson, William G; Tarkington, Lynn G; Yancy, Clyde W
2010 Dec 14;56(25):e50-103, Journal of the American College of Cardiology
— id: 137816, year: 2010, vol: 56, page: e50, stat: Journal Article,

Renal impairment and heart failure with preserved ejection fraction early post-myocardial infarction
Jorapur, Vinod; Lamas, Gervasio A; Sadowski, Zygmunt P; Reynolds, Harmony R; Carvalho, Antonio C; Buller, Christopher E; Rankin, James M; Renkin, Jean; Steg, Philippe Gabriel; White, Harvey D; Vozzi, Carlos; Balcells, Eduardo; Ragosta, Michael; Martin, C Edwin; Srinivas, Vankeepuram S; Wharton Iii, William W; Abramsky, Staci; Mon, Ana C; Kronsberg, Shari S; Hochman, Judith S
2010 Jan 26;2(1):13-18, World journal of cardiology
AIM: To study if impaired renal function is associated with increased risk of peri-infarct heart failure (HF) in patients with preserved ejection fraction (EF). METHODS: Patients with occluded infarct-related arteries (IRAs) between 1 to 28 d after myocardial infarction (MI) were grouped into chronic kidney disease (CKD) stages based on estimated glomerular filtration rate (eGFR). Rates of early post-MI HF were compared among eGFR groups. Logistic regression was used to explore independent predictors of HF. RESULTS: Reduced eGFR was present in 71.1% of 2160 patients, with significant renal impairment (eGFR < 60 mL/min every 1.73 m(2)) in 14.8%. The prevalence of HF was higher with worsening renal function: 15.5%, 17.8% and 29.4% in patients with CKD stages 1, 2 and 3 or 4, respectively (P < 0.0001), despite a small absolute difference in mean EF across eGFR groups: 48.2 +/- 10.0, 47.9 +/- 11.3 and 46.2 +/- 12.1, respectively (P = 0.02). The prevalence of HF was again higher with worsening renal function among patients with preserved EF: 10.1%, 13.6% and 23.6% (P < 0.0001), but this relationship was not significant among patients with depressed EF: 27.1%, 26.2% and 37.9% (P = 0.071). Moreover, eGFR was an independent correlate of HF in patients with preserved EF (P = 0.003) but not in patients with depressed EF (P = 0.181). CONCLUSION: A significant proportion of post-MI patients with occluded IRAs have impaired renal function. Impaired renal function was associated with an increased rate of early post-MI HF, the association being strongest in patients with preserved EF. These findings have implications for management of peri-infarct HF
— id: 137113, year: 2010, vol: 2, page: 13, stat: Journal Article,

Impact of left ventricular ejection fraction on clinical outcomes over five years after infarct-related coronary artery recanalization (from the Occluded Artery Trial [OAT])
Kruk, Mariusz; Buller, Christopher E; Tcheng, James Enlou; Dzavik, Vladimir; Menon, Venugopal; Mancini, G B John; Forman, Sandra A; Kurray, Peter; Busz-Papiez, Benita; Lamas, Gervasio A; Hochman, Judith S
2010 Jan 1;105(1):10-16, American journal of cardiology
In the Occluded Artery Trial (OAT), percutaneous coronary intervention (PCI) of an infarct-related artery on days 3 to 28 after acute myocardial infarction was of no benefit compared to medical therapy alone. The present analysis was conducted to determine whether PCI might provide benefit to the subgroup of higher risk patients with a depressed ejection fraction (EF). Of 2,185 analyzed patients (age 58.6 +/- 11.0 years) with infarct-related artery occlusion on days 3 to 28 after acute myocardial infarction in the Occluded Artery Trial, 1,094 were assigned to PCI and 1,091 to medical therapy. The primary end point was a composite of death, reinfarction, and New York Heart Association class IV heart failure. The outcomes were analyzed by EF (first tertile, EF < or =44%, vs second and third tertiles combined, EF >44%). Interaction of the treatment effect with EF on the study outcomes were examined using the Cox survival model. The 5-year rates of the primary end point (death, reinfarction, or New York Heart Association class IV heart failure) were not different in either subgroup (PCI vs medical therapy, hazard ratio 1.25, 99% confidence interval 0.83 to 1.88, for EF < or =44%; hazard ratio 0.98, 99% confidence interval 0.64 to 1.50, for EF >44%). However, in patients with an EF >44%, PCI reduced the rate of subsequent revascularization (p = 0.004, interaction p = 0.05). In conclusion, optimal medical therapy remains the overall treatment of choice for stable patients with a persistent total occlusion of the infarct-related artery after acute myocardial infarction, irrespective of the baseline EF. In patients with normal or moderately impaired left ventricular contractility, PCI reduced the need for subsequent revascularization but did not otherwise improve outcomes
— id: 133449, year: 2010, vol: 105, page: 10, stat: Journal Article,

South Asians and risk of cardiovascular disease: current insights and trends
Mangalmurti, Sandeep S; Paley, Ari; Gany, Francesca; Fisher, Edward A; Hochman, Judith S
2010 Autumn;20(4):474-478, Ethnicity & disease
Patients from the Indian subcontinent have a distinct cardiovascular risk profile with profound health consequences. South Asians tend to develop more severe coronary artery disease at a younger age, and may also suffer from earlier myocardial infarction and heart failure. The genesis of this risk is multi-factorial. One important culprit is increased insulin resistance, possibly due to recently identified genetic polymorphisms. Another possible explanation is subclinical inflammation and a prothrombotic environment, as evidenced by increased levels of homocysteine, plasminogen activator inhibitor-1, and fibrinogen. The lipid profile of South Asians may play a role, as this population is known to have elevated levels of lipoprotein (a), as well as lower levels of HDL. In addition, this HDL may be dysfunctional, as this population may have a higher prevalence of low levels of HDL2b, as well as an increased preponderance of smaller HDL. Current guidelines for primary and secondary prevention have not reflected our growing insight into the unique characteristics of the South Asian population, and may need to evolve to reflect our knowledge
— id: 125449, year: 2010, vol: 20, page: 474, stat: Journal Article,

Clinical features and outcomes of women with unstable ischemic heart disease: observations from metabolic efficiency with ranolazine for less ischemia in non-ST-elevation acute coronary syndromes-thrombolysis in myocardial infarction 36 (MERLIN-TIMI 36)
Mega, Jessica L; Hochman, Judith S; Scirica, Benjamin M; Murphy, Sabina A; Sloan, Sarah; McCabe, Carolyn H; Merlini, Piera; Morrow, David A
2010 Apr 27;121(16):1809-1817, Circulation
BACKGROUND: The pathobiological basis of ischemic heart disease and thus the manifestations and response to therapy can differ between women and men. In prior studies, sex-based treatment differences have been observed with the antiischemic ranolazine, with a possibly diminished effect in women. METHODS AND RESULTS: We conducted a prospectively planned analysis of the clinical, biomarker, angiographic, and continuous ECG features and 1-year outcomes of women with unstable ischemic heart disease randomized to ranolazine or placebo in Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndromes-Thrombolysis in Myocardial Infarction 36 (MERLIN-TIMI 36). Compared with men (n=4269), women (n=2291) were older with more risk factors (P<0.001). On presentation, women were less likely than men to have significant epicardial coronary artery disease (no stenosis >or=50% on angiography, 19.4% versus 8.6%; P<0.001) or elevated troponin (57.1% versus 68.9%; P<0.001). Yet, women were more likely to have an elevated B-type natriuretic peptide (47.0% versus 40.2%; P<0.001), worse median angina frequency scores (80 versus 100; P<0.001), and an ischemic episode on continuous ECG administered during the first 7 days (22.5% versus 19.3%; P=0.0025). Women and men were at similar adjusted risk for the primary end point of cardiovascular death, myocardial infarction, or recurrent ischemia (adjusted hazard ratio, 1.11; 95% confidence interval, 0.96 to 1.29; P=0.15). Ranolazine was associated with a significant reduction in recurrent ischemia in women (13.0% versus 18.2%; hazard ratio, 0.71; 95% confidence interval, 0.57 to 0.88; P=0.002). CONCLUSIONS: Women with a clinical syndrome consistent with unstable ischemic heart disease, despite having less obstructive coronary artery disease, were more likely than men to report anginal episodes and had more recorded ischemic periods on continuous ECG. In this setting, ranolazine may be a particularly useful antiischemic agent in women. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00099788
— id: 137112, year: 2010, vol: 121, page: 1809, stat: Journal Article,

Heartbreak
Reynolds, Harmony R; Hochman, Judith S
2010 Jun;31(12):1433-1435, European heart journal
— id: 134366, year: 2010, vol: 31, page: 1433, stat: Journal Article,

A severity scoring system for risk assessment of patients with cardiogenic shock: a report from the SHOCK Trial and Registry
Sleeper, Lynn A; Reynolds, Harmony R; White, Harvey D; Webb, John G; Dzavik, Vladimir; Hochman, Judith S
2010 Sep;160(3):443-450, American heart journal
BACKGROUND: Early revascularization (ERV) is beneficial in the management of cardiogenic shock (CS) complicating myocardial infarction. The severity of CS varies widely, and identification of independent risk factors for outcome is needed. The effect of ERV on mortality in different risk strata is also unknown. We created a severity scoring system for CS and used it to examine the potential benefit of ERV in different risk strata using data from the SHOCK Trial and Registry. METHODS: Data from 1,217 patients (294 from the randomized trial and 923 from the registry) with CS due to pump failure were included in a Stage 1 severity scoring system using clinical variables. A Stage 2 scoring system was developed using data from 872 patients who had invasive hemodynamic measurements. The outcome was in-hospital mortality at 30 days. RESULTS: In-hospital mortality at 30 days was 57%. Multivariable modeling identified 8 risk factors (Stage 1): age, shock on admission, clinical evidence of end-organ hypoperfusion, anoxic brain damage, systolic blood pressure, prior coronary artery bypass grafting, noninferior myocardial infarction, and creatinine > or = 1.9 mg/dL (c-statistic = 0.74). Mortality ranged from 22% to 88% by score category. The ERV benefit was greatest in moderate- to high-risk patients (P = .02). The Stage 2 model based on patients with pulmonary artery catheterization included age, end-organ hypoperfusion, anoxic brain damage, stroke work, and left ventricular ejection fraction <28% (c-statistic = 0.76). In this cohort, the effect of ERV did not vary by risk stratum. CONCLUSIONS: Simple clinical predictors provide good discrimination of mortality risk in CS complicating myocardial infarction. Early revascularization is associated with improved survival across a broad range of risk strata
— id: 137110, year: 2010, vol: 160, page: 443, stat: Journal Article,

Impact of collateral flow to the occluded infarct-related artery on clinical outcomes in patients with recent myocardial infarction: a report from the randomized occluded artery trial
Steg, Ph Gabriel; Kerner, Arthur; Mancini, G B John; Reynolds, Harmony R; Carvalho, Antonio C; Fridrich, Viliam; White, Harvey D; Forman, Sandra A; Lamas, Gervasio A; Hochman, Judith S; Buller, Christopher E
2010 Jun 29;121(25):2724-2730, Circulation
BACKGROUND: Collateral flow to the infarct artery territory after acute myocardial infarction may be associated with improved clinical outcomes and may also impact the benefit of subsequent recanalization of an occluded infarct-related artery. METHODS AND RESULTS: To understand the association between baseline collateral flow to the infarct territory on clinical outcomes and its interaction with percutaneous coronary intervention of an occluded infarct artery, long-term outcomes in 2173 patients with total occlusion of the infarct artery 3 to 28 days after myocardial infarction from the randomized Occluded Artery Trial were analyzed according to angiographic collaterals documented at study entry. There were important differences in baseline clinical and angiographic characteristics as a function of collateral grade, with generally lower-risk characteristics associated with higher collateral grade. Higher collateral grade was associated with lower rates of death (P=0.009), class III and IV heart failure (P<0.0001) or either (P=0.0002) but had no association with the risk of reinfarction. However, by multivariate analysis, collateral flow was neither an independent predictor of death nor of the primary end point of the trial (composite of death, reinfarction, or class IV heart failure). There was no interaction between angiographic collateral grade and the results of randomized treatment assignment (percutaneous coronary intervention or medical therapy alone) on clinical outcomes. CONCLUSIONS: In recent myocardial infarction, angiographic collaterals to the occluded infarct artery are correlates but not independent predictors of major clinical outcomes. Late recanalization of the infarct artery in addition to medical therapy shows no benefit compared with medical therapy alone, regardless of the presence or absence of collaterals. Therefore, revascularization decisions in patients with recent myocardial infarction should not be based on the presence or grade of angiographic collaterals. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004562
— id: 137111, year: 2010, vol: 121, page: 2724, stat: Journal Article,

Myocardial perfusion grade after late infarct artery recanalization is associated with global and regional left ventricular function at one year: analysis from the Total Occlusion Study of Canada-2
Steigen, Terje K; Buller, Christopher E; Mancini, G B John; Jorapur, Vinod; Cantor, Warren J; Rankin, James M; Thomas, Boban; Webb, John G; Kronsberg, Shari S; Atchison, Deborah J; Lamas, Gervasio A; Hochman, Judith S; Dzavik, Vladimir
2010 Dec;3(6):549-555, Circulation: Cardiovascular Interventions
BACKGROUND: Whether myocardial perfusion grade (MPG) following late recanalization of infarct-related arteries (IRAs) predicts left ventricular (LV) function recovery beyond the acute phase of myocardial infarction (MI) is unknown. METHODS AND RESULTS: The Total Occlusion Study of Canada-2 enrolled stable patients with a persistently occluded IRA beyond 24 hours and up to 28 days post-MI. We studied the relationship between the initial MPG and changes in LV function and volume as well as the change in MPG from immediate post-percutaneous coronary intervention (PCI) to 1 year in 139 PCI patients with thrombolysis in myocardial infarction grade 3 epicardial flow post-PCI and with paired values grouped into impaired or good MPG groups (MPG 0/1 or MPG 2/3). MPG 0/1 patients were more likely to have received thrombolytic therapy and to have a left anterior descending IRA. They had lower blood pressure and LV ejection fraction (LVEF) and a higher heart rate and systolic sphericity index at baseline. Changes in the MPG 0/1 and MPG 2/3 groups from baseline to 1 year were LVEF, 3.3+/-9.0% and 4.8+/-8.9% (P=0.42); LV end-systolic volume index (LVESVI), -1.1+/-9.2 and -4.7+/-12.3 mL/m(2) (P=0.25); LV end-diastolic volume index (LVEDVI), 0.08+/-19.1 and -2.4+/-22.2 mL/m(2) (P=0.67); and SDs/chord for infarct zone wall motion index (WMI), 0.38+/-0.70 and 0.84+/-1.11 (P=0.01). By covariate-adjusted analysis, post-PCI MPG 0/1 predicted lower WMI (P<0.001), lower LVEF (P<0.001), and higher LVESVI (P<0.01) but not LVEDVI at 1 year. Of the MPG 0/1 patients, 60% were MPG 2 or 3 at 1 year. CONCLUSIONS: Preserved MPG is present in a high proportion of patients following late PCI of occluded IRAs post-MI. Poor MPG post-PCI frequently improves MPG over 1 year. MPG graded after IRA recanalization undertaken days to weeks post MI is associated with LV recovery, indicating that MPG determined in the subacute post-MI period remains a marker of viability. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00025766
— id: 137108, year: 2010, vol: 3, page: 549, stat: Journal Article,

Hormone replacement therapy among postmenopausal women presenting with acute myocardial infarction: insights from the GUSTO-III trial
Tackett, Andrea H; Bailey, Alison L; Foody, Joanne Micale; Miller, Julie M; Apperson-Hansen, Carolyn; Ohman, E Magnus; Hochman, Judith S; Karnash, Sharon L; Califf, Robert M; Topol, Eric J; Moliterno, David J
2010 Oct;160(4):678-684, American heart journal
BACKGROUND: The role of hormone replacement therapy (HRT) in the prevention of cardiovascular disease has been controversial. In large observational studies, HRT appears to lower cardiovascular disease risk. However, prospective randomized trials do not substantiate this. METHODS: We sought to characterize the use of HRT in women presenting with acute myocardial infarction and to investigate an association between HRT and inhospital or 30-day outcomes among women enrolled in the Global Use of Strategies to Open Occluded Coronary Arteries III (GUSTO-III) trial. Of the 15,059 patients in GUSTO-III, 4124 were women. Menopausal status, HRT use, and clinical outcomes data were prospectively collected. RESULTS: Postmenopausal women taking HRT were significantly younger than those not taking HRT, and US women were more likely to be prescribed HRT than non-US women. While unadjusted 30-day mortality was substantially lower in HRT patients (6.1% vs 12.7%, P < .001), HRT use was not independently predictive of mortality after correcting for baseline differences (chi(2) = 0.15, P = .70). CONCLUSION: Hormone replacement therapy appears to have no early mortality benefit in women sustaining acute myocardial infarction. These findings further challenge the role of HRT in cardiovascular medicine
— id: 137109, year: 2010, vol: 160, page: 678, stat: Journal Article,

Sex differences in mortality following acute coronary syndromes
Berger, Jeffrey S; Elliott, Laine; Gallup, Dianne; Roe, Matthew; Granger, Christopher B; Armstrong, Paul W; Simes, R John; White, Harvey D; Van de Werf, Frans; Topol, Eric J; Hochman, Judith S; Newby, L Kristin; Harrington, Robert A; Califf, Robert M; Becker, Richard C; Douglas, Pamela S
2009 Aug 26;302(8):874-882, JAMA
CONTEXT: Conflicting information exists about whether sex differences modulate short-term mortality following acute coronary syndromes (ACS). OBJECTIVES: To investigate the relationship between sex and 30-day mortality in ACS, and to determine whether this relationship was modified by clinical syndrome or coronary anatomy using a large database across the spectrum of ACS and adjusting for potentially confounding clinical covariates. DESIGN, SETTING, AND PARTICIPANTS: A convenience sample of patients pooled from 11 independent, international, randomized ACS clinical trials between 1993 and 2006 whose databases are maintained at the Duke Clinical Research Institute, Durham, North Carolina. Of 136 247 patients, 38 048 (28%) were women; 102 004 (26% women) with ST-segment elevation myocardial infarction (STEMI), 14 466 (29% women) with non-STEMI (NSTEMI), and 19 777 (40% women) with unstable angina. MAIN OUTCOME MEASURE: Thirty-day mortality following ACS. RESULTS: Thirty-day mortality was 9.6% in women and 5.3% in men (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.83-2.00). After multivariable adjustment, mortality was not significantly different between women and men (adjusted OR, 1.06; 95% CI, 0.99-1.15). A significant sex by type of ACS interaction was demonstrated (P < .001). In STEMI, 30-day mortality was higher among women (adjusted OR, 1.15; 95% CI, 1.06-1.24), whereas in NSTEMI (adjusted OR, 0.77; 95% CI, 0.63-0.95) and unstable angina, mortality was lower among women (adjusted OR, 0.55; 95% CI, 0.43-0.70). In a cohort of 35 128 patients with angiographic data, women more often had nonobstructive (15% vs 8%) and less often had 2-vessel (25% vs 28%) and 3-vessel (23% vs 26%) coronary disease, regardless of ACS type. After additional adjustment for angiographic disease severity, 30-day mortality among women was not significantly different than men, regardless of ACS type. The relationship between sex and 30-day mortality was similar across the levels of angiographic disease severity (P for interaction = .70). CONCLUSIONS: Sex-based differences existed in 30-day mortality among patients with ACS and vary depending on clinical presentation. However, these differences appear to be largely explained by clinical differences at presentation and severity of angiographically documented disease
— id: 101900, year: 2009, vol: 302, page: 874, stat: Journal Article,

Percutaneous coronary intervention in the Occluded Artery Trial: procedural success, hazard, and outcomes over 5 years
Buller, Christopher E; Rankin, Jamie M; Carere, Ronald G; Buszman, Pawel E; Pfisterer, Matthias E; Dzavik, Vladimir; Thomas, Boban; Forman, Sandra; Ruzyllo, Witold; Mancini, G B John; Michalis, Lampros K; Abreu, Pedro F; Lamas, Gervasio A; Hochman, Judith S
2009 Sep;158(3):408-415, American heart journal
BACKGROUND: The Occluded Artery Trial (OAT) was a 2,201-patient randomized clinical trial comparing routine stent-based percutaneous coronary intervention (PCI) versus optimal medical therapy alone in stable myocardial infarction (MI) survivors with persistent infarct-related artery occlusion identified day 3 to 28 post MI. Intent-to-treat analysis showed no difference between strategies with respect to the incidence of new class IV congestive heart failure, MI, or death. The influence of PCI failure, procedural hazard, and crossover on trial results has not been reported. METHODS: Study angiograms were analyzed and adjudicated centrally. Factors associated with PCI failure were examined. Time-to-event analysis using the OAT primary outcome was performed by PCI success status. Landmark analysis (up to and beyond 30 days) partitioned early hazard versus late outcome according to treatment received. RESULTS: Percutaneous coronary intervention was adjudicated successful in >87%. Percutaneous coronary intervention failure rates were similar in US and non-US sites, and did not significantly influence outcome at 60 months (hazard ratio for success vs fail 0.79, 99% CI 0.45-1.40, P = .29). Partitioning of early procedural hazard revealed no late benefit for PCI (hazard ratio for PCI success vs medical therapy alone 1.06, 99% CI 0.75-1.50, P = .66). CONCLUSIONS: Percutaneous coronary intervention failure and complication rates in the OAT were low. Neither PCI failure nor early procedural hazard substantively influenced the primary trial results
— id: 137117, year: 2009, vol: 158, page: 408, stat: Journal Article,

Impact of stress testing before percutaneous coronary intervention or medical management on outcomes of patients with persistent total occlusion after myocardial infarction: analysis from the occluded artery trial
Cantor, Warren J; Baptista, Sergio B; Srinivas, Vankeepuram S; Pearte, Camille A; Menon, Venu; Sadowski, Zygmunt; Ross, John R; Meciar, Peter; Nikolsky, Eugenia; Forman, Sandra A; Lamas, Gervasio A; Hochman, Judith S
2009 Apr;157(4):666-672, American heart journal
BACKGROUND: In the Occluded Artery Trial (OAT), 2,201 stable patients with an occluded infarct-related artery (IRA) were randomized to percutaneous coronary intervention (PCI) or optimal medical treatment alone (MED). There was no difference in the primary end point of death, reinfarction, or congestive heart failure (CHF). We examined the prognostic impact of prerandomization stress testing. METHODS: Stress testing was required by protocol except for patients with single-vessel disease and akinesis/dyskinesis of the infarct zone. The presence of severe inducible ischemia was an exclusion criterion for OAT. We compared outcomes based on performance and results of stress testing. RESULTS: Five hundred ninety-eight (27%) patients (297 PCI, 301 MED) underwent stress testing. Radionuclide imaging or stress echocardiography was performed in 40%. Patients who had stress testing were younger (57 vs 59 years); had higher ejection fractions (49% vs 47%); and had lower rates of death (7.8% vs 13.2%), class IV CHF (2.4% vs 5.5%), and the primary end point (13.9% vs 18.9%) than patients without stress testing (all P < .01). Mild-moderate ischemia was observed in 40% of patients with stress testing and was not related to outcomes. Among patients with inducible ischemia, outcomes were similar for PCI and MED (all P > .10). CONCLUSIONS: In OAT, patients who underwent stress testing had better outcomes than patients who did not, likely related to differences in baseline characteristics. In patients managed with optimal medical therapy or PCI, mild-moderate inducible ischemia was not related to outcomes. The lack of benefit for PCI compared to MED alone was consistent regardless of whether stress testing was performed or inducible ischemia was present
— id: 101572, year: 2009, vol: 157, page: 666, stat: Journal Article,

Angiographic and clinical outcomes of drug-eluting versus bare metal stent deployment in the Occluded Artery Trial
Dzavik, Vladimir; Buller, Christopher E; Devlin, Gerard; Carere, Ronald G; Mancini, G B John; Cantor, Warren J; Buszman, Pawel E; Rankin, James M; Vozzi, Carlos; Ross, John R; Forman, Sandra; Barton, Bruce A; Lamas, A Gervasio A; Hochman, Judith S
2009 May 1;73(6):771-779, Catheterization & cardiovascular interventions
BACKGROUND: The majority of patients randomized to percutaneous coronary intervention (PCI) in the Occluded Artery Trial (OAT) and its angiographic substudy, the Total Occlusion Study of Canada 2 (TOSCA-2) were treated with bare metal stents (BMS). We aimed to determine if stenting of the target occlusion in OAT with drug-eluting stents (DES) was associated with more favorable angiographic results and clinical outcome when compared with treatment with BMS. METHODS: TOSCA-2 DES was a prospective nonrandomized substudy that provided 1-year angiographic comparison of late loss and reocclusion in 25 patients treated with DES and in 128 treated with BMS. In addition, all PCI-assigned patients enrolled from the time when DES were first utilized were similarly categorized (DES n = 77, and BMS n = 386) and compared using the 3-year cumulative OAT primary combined endpoint of death, myocardial infarction, or Class-IV heart failure, as well as angina. RESULTS: In-segment late loss was 0.14 +/- 0.45 mm for DES and 0.75 +/- 0.86 mm for BMS (P < 0.001). Corresponding binary restenosis rates were 13.0% and 44.3% (P = 0.005). Occlusion at 1 year was observed in 4.0 and 12.1%, respectively (P = 0.23). The 3-year cumulative primary event rate was 13.8% with DES and 12.5% with BMS (hazard ratio 1.08, 99% confidence intervals 0.44, 2.64; P = 0.83). Angina over time occurred less frequently in the DES group (P = 0.01). CONCLUSIONS: Although the reduction of late loss and trend to reduction in reocclusion with the use of DES for PCI of persistently occluded IRA 3-28 days post myocardial infarction did not translate into a signal for reduction in death, reinfarction, or Class IV heart failure, DES use was associated with less angina over time. Further follow-up is warranted
— id: 101573, year: 2009, vol: 73, page: 771, stat: Journal Article,

Cardiogenic shock without flow-limiting angiographic coronary artery disease: (from the Should We Emergently Revascularize Occluded Coronary Arteries for Cardiogenic Shock Trial and Registry)
French, John K; Harkness, Shannon; Sleeper, Lynn; Wong, S Chiu; Col, Jacques; Dzavik, Vladimir; White, Harvey D; Hochman, Judith S
2009 Jul 1;104(1):24-28, American journal of cardiology
Myocardial infarction often develops when thrombosis occurs at lesions that have not previously been flow limiting. However, the development of cardiogenic shock complicating acute myocardial infarction in such circumstances has received little attention. The characteristics of 15 patients with cardiogenic shock who had no flow-limiting angiographic stenoses were compared with those of 767 patients with > or =1 stenosis who were enrolled in the Should We Emergently Revascularize Occluded Coronary Arteries for Cardiogenic Shock (SHOCK) trial and registry. Compared with patients with > or =1 flow-limiting stenosis, patients with no flow-limiting stenoses were less likely to have pulmonary edema on chest x-ray (29% vs 62%, p = 0.008) and to be white (53% vs 82%, p = 0.011), and they had lower median highest creatine kinase levels (702 vs 2,731 U/L, p = 0.018). For SHOCK trial patients, 1-year survival was 49% for patients with > or =1 flow-limiting stenosis and 71% for those with no flow-limiting stenoses (p = 0.268). In conclusion, patients with cardiogenic shock without flow-limiting stenosis have different characteristics, and potentially disease mechanisms, and they do not require revascularization
— id: 101568, year: 2009, vol: 104, page: 24, stat: Journal Article,

Characterization and outcomes of women and men with non-ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: results from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative
Gehrie, Erika R; Reynolds, Harmony R; Chen, Anita Y; Neelon, Brian H; Roe, Matthew T; Gibler, W Brian; Ohman, E Magnus; Newby, L Kristin; Peterson, Eric D; Hochman, Judith S
2009 Oct;158(4):688-694, American heart journal
BACKGROUND: Women with non-ST-segment elevation myocardial infarction (NSTEMI) who undergo coronary angiography have no obstructive coronary lesions more often than men. Sex-specific characteristics and outcomes of patients without obstructive coronary artery disease (CAD) have not been described previously. METHODS: Using data from NSTEMI patients enrolled in CRUSADE from 2001 to 2005, we evaluated differences in clinical features and in-hospital outcomes between men and women with no obstructive CAD. RESULTS: After excluding patients with missing catheterization and sex data (n = 1,494), previous coronary artery bypass grafting or percutaneous coronary intervention (47,907), catheterization contraindications (n = 6,588), and missing obstructive CAD status (n = 1,565), there were 55,514 patients (68.4%) with NSTE acute coronary syndromes (ACS) who underwent angiography (among women, 62.1% [21,294/34,290], and among men, 73% [34,220/46,875]; P < .001). Among these, a total of 5,538 patients (10.0%) had nonnonobstructive CAD-15.1% (3,221/21,294) of women and 6.8% (2,317/34,220) of men (P < .0001). In patients without obstructive CAD, women were as likely as men to have MI (troponin elevation in 89% vs 87%, P = .37). Women and men were equally likely to have larger troponin elevations (58.9% vs 58.6% with troponin >5x upper limit of normal, P = .69, respectively). In NSTEMI patients without obstructive CAD, in-hospital death (0.6% women vs 0.7% men) and cardiogenic shock (1.0% women vs 0.7% men) were infrequent. CONCLUSIONS: Among NSTE ACS patients undergoing coronary angiography, absence of obstructive CAD is more common in women than men. Although nonobstructive CAD was twice as common among women with NSTEMI, sex differences in characteristics and outcomes were similar to those found with obstructive CAD. Unadjusted in-hospital outcomes of NSTEMI patients with nonobstructive CAD are favorable in both sexes. Whether the underlying pathophysiology of NSTE ACS without documentation of obstructive CAD is different between women and men requires further study
— id: 102938, year: 2009, vol: 158, page: 688, stat: Journal Article,

Contemporary management of cardiogenic shock: age is opportunity
Hochman, Judith S; Skolnick, Adam H
2009 Feb;2(2):153-155, JACC: Cardiovascular Interventions
— id: 101107, year: 2009, vol: 2, page: 153, stat: Journal Article,

Predictors of 30-day mortality in patients with refractory cardiogenic shock following acute myocardial infarction despite a patent infarct artery
Katz, Jason N; Stebbins, Amanda L; Alexander, John H; Reynolds, Harmony R; Pieper, Karen S; Ruzyllo, Witold; Werdan, Karl; Geppert, Alexander; Dzavik, Vladimir; Van de Werf, Frans; Hochman, Judith S
2009 Oct;158(4):680-687, American heart journal
BACKGROUND: Little is known about predictors of survival in patients with persistent shock following acute myocardial infarction (MI) despite a patent infarct artery. METHODS: We examined data from TRIUMPH, a multicenter randomized clinical trial of the nitric oxide synthase inhibitor, L-N(G)-monomethyl-arginine, in patients with persistent vasopressor-dependent cardiogenic shock complicating acute MI at least 1 hour after established infarct-related artery patency. Patients who died within 30 days were compared with those who survived. Continuous variables were assessed using the Wilcoxon rank sum and categorical variables using the chi(2) test. Prespecified baseline variables were included in a multivariable logistic regression model to predict mortality. A second model incorporating baseline vasopressors and dosages and a third model including change in systolic blood pressure at 2 hours were also developed. Bootstrapping was used to assess the stability of model variables. RESULTS: Of 396 patients, 180 (45.5%) died within 30 days. Systolic blood pressure (SBP), measured on vasopressor support, and creatinine clearance were significant predictors of mortality in all models. The number of vasopressors and norepinephrine dose were also predictors of mortality in the second model, but the latter was no longer significant when change in SBP at 2 hours was added as a covariate in the third model. CONCLUSIONS: The SBP, creatinine clearance, and number of vasopressors are significant predictors of mortality in patients with persistent vasopressor-dependent cardiogenic shock following acute MI despite a patent infarct artery. These prognostic variables may be useful for risk-stratification and in selecting patients for investigation of additional therapies
— id: 137116, year: 2009, vol: 158, page: 680, stat: Journal Article,

2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Kushner, Frederick G; Hand, Mary; Smith, Sidney C Jr; King, Spencer B 3rd; Anderson, Jeffrey L; Antman, Elliott M; Bailey, Steven R; Bates, Eric R; Blankenship, James C; Casey, Donald E Jr; Green, Lee A; Hochman, Judith S; Jacobs, Alice K; Krumholz, Harlan M; Morrison, Douglass A; Ornato, Joseph P; Pearle, David L; Peterson, Eric D; Sloan, Michael A; Whitlow, Patrick L; Williams, David O
2009 Dec 1;54(23):2205-2241, Journal of the American College of Cardiology
— id: 137115, year: 2009, vol: 54, page: 2205, stat: Journal Article,

2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Kushner, Frederick G; Hand, Mary; Smith, Sidney C Jr; King, Spencer B 3rd; Anderson, Jeffrey L; Antman, Elliott M; Bailey, Steven R; Bates, Eric R; Blankenship, James C; Casey, Donald E Jr; Green, Lee A; Hochman, Judith S; Jacobs, Alice K; Krumholz, Harlan M; Morrison, Douglass A; Ornato, Joseph P; Pearle, David L; Peterson, Eric D; Sloan, Michael A; Whitlow, Patrick L; Williams, David O
2009 Dec 1;120(22):2271-2306, Circulation
— id: 128809, year: 2009, vol: 120, page: 2271, stat: Journal Article,

2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Kushner, Frederick G; Hand, Mary; Smith, Sidney C Jr; King, Spencer B 3rd; Anderson, Jeffrey L; Antman, Elliott M; Bailey, Steven R; Bates, Eric R; Blankenship, James C; Casey, Donald E Jr; Green, Lee A; Jacobs, Alice K; Hochman, Judith S; Krumholz, Harlan M; Morrison, Douglass A; Ornato, Joseph P; Pearle, David L; Peterson, Eric D; Sloan, Michael A; Whitlow, Patrick L; Williams, David O
2009 Dec 1;74(7):E25-E68, Catheterization & cardiovascular interventions
— id: 137114, year: 2009, vol: 74, page: E25, stat: Journal Article,

Causes of death in early MI survivors with persistent infarct artery occlusion: results from the Occluded Artery Trial (OAT)
Lang, Irene M; Forman, Sandra A; Maggioni, Aldo P; Ruzyllo, Witold; Renkin, Jean; Vozzi, Carlos; Steg, P Gabriel; Hernandez-Garcia, Jose-Maria; Zmudka, Krzysztof; Jimenez-Navarro, Manuel; Sopko, George; Lamas, Gervasio A; Hochman, Judith S
2009 Nov;5(5):610-618, EuroIntervention
AIMS: OAT randomised patients with an occluded infarct artery three to 28 days after myocardial infarction (MI). The study demonstrated that PCI did not reduce the occurrence of the primary composite endpoint of death, re-MI, and New York Heart Association class IV heart failure in comparison with patients assigned to optimal medical therapy alone (MED). In view of prior literature in similar cohorts showing fewer sudden cardiac deaths and less left ventricular (LV) remodelling, but excess re-MI with PCI, causes of death were analysed in more detail. METHODS AND RESULTS: Stepwise Cox regression was used to examine baseline variables associated with causes of death. The immediate and primary cause of death did not differ between 1,101 PCI and 1,100 MED patients. One-year cardiovascular death rates were 3.8% for the PCI group, and 3.7% for the MED group, and 0.9% per year for the next four years in both groups. Five of six cases of cardiac rupture occurred in patients undergoing PCI. CONCLUSIONS: In stable post-MI patients with occlusion of the infarct-related artery, PCI did not change the rate or cause of death. The observation that the majority of cardiac ruptures occurred in patients undergoing PCI deserves further investigation
— id: 133759, year: 2009, vol: 5, page: 610, stat: Journal Article,

Antithrombotic therapy and outcomes of patients with atrial fibrillation following primary percutaneous coronary intervention: results from the APEX-AMI trial
Lopes, Renato D; Elliott, Laine E; White, Harvey D; Hochman, Judith S; Van de Werf, Frans; Ardissino, Diego; Nielsen, Torsten T; Weaver, W Douglas; Widimsky, Petr; Armstrong, Paul W; Granger, Christopher B
2009 Aug;30(16):2019-2028, European heart journal
AIMS: To assess the incidence and timing of atrial fibrillation (AF), describe antithrombotic therapy use, and evaluate the association of AF with 90 day mortality and other secondary clinical outcomes. METHODS AND RESULTS: We studied 5745 ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention (PCI) in APEX-AMI. Approximately 11% had AF during hospitalization. Atrial fibrillation prevalence at baseline and at discharge was 4.8% [confidence interval (CI) 4.3-5.4%] and 2.5% (CI 2.1-2.9%), respectively. The proportion of 5466 patients without AF at baseline who developed new onset AF was 6.3% (CI 5.6-6.9%). This corresponded to 9.3 cases of new onset AF/1000 patient days at risk. New onset AF was independently associated with 90 day mortality [adjusted hazard ratio (HR) 1.81; 95% CI 1.06-3.09; P = 0.029] after accounting for baseline covariates and in-hospital procedures and complications. New onset AF was associated with shock (adjusted HR 3.81; 95% CI 1.88-7.70; P = 0.0002), congestive heart failure (adjusted HR 2.66; 95% CI 1.74-4.06; P < 0.0001), and stroke (adjusted HR 2.98; 95% CI 1.47-6.04; P = 0.0024) in models accounting for baseline covariates. Of AF patients, 55% did not receive oral anticoagulation therapy at discharge. Among patients with coronary stents, 5.1% were discharged on triple therapy. Patients at highest risk of stroke (CHADS(2) score > or =2) were least likely to receive oral anticoagulation at discharge (39%). Warfarin use in patients with AF at discharge (43.4%) was associated with lower rates of 90 day mortality and stroke. CONCLUSION: Atrial fibrillation prevalence at baseline and at discharge was 4.8 and 2.5%, respectively. The proportion of patients who developed new onset AF was 6.3%. New onset AF was independently associated with 90 day mortality and was a marker of adverse outcomes in patients undergoing primary PCI
— id: 101569, year: 2009, vol: 30, page: 2019, stat: Journal Article,

Late coronary intervention for totally occluded left anterior descending coronary arteries in stable patients after myocardial infarction: Results from the Occluded Artery Trial (OAT)
Malek, Lukasz A; Reynolds, Harmony R; Forman, Sandra A; Vozzi, Carlos; Mancini, G B John; French, John K; Dziarmaga, Mieczyslaw; Renkin, Jean P; Kochman, Janusz; Lamas, Gervasio A; Hochman, Judith S
2009 Apr;157(4):724-732, American heart journal
BACKGROUND: We analyzed a prespecified hypothesis of the Occluded Artery Trial (OAT) that late percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) would be most beneficial for patients with anterior myocardial infarction (MI). METHODS: Two thousand two hundred one stable, high-risk patients with total occlusion of the IRA (793 left anterior descending [LAD]) on days 3 to 28 (minimum of 24 hours) after MI were randomized to PCI and stenting with optimal medical therapy (1,101 patients) or to optimal medical therapy alone (1,100 patients). The primary end point was a composite of death, recurrent MI, or hospitalization for class IV heart failure. RESULTS: The 5-year cumulative primary end point rate was more frequent in the LAD group (19.5%) than in the non-LAD group (16.4%) (HR 1.34, 99% CI 1.00-1.81, P = .01). Within the LAD group, the HR for the primary end point in the PCI group (22.7%) compared with the medical therapy group (16.4%) was 1.35 (99% CI 0.86-2.13, P = .09), whereas in the non-LAD group the HR for the primary end point in PCI (16.9%) compared with medical therapy (15.8%) was 1.03 (99% CI 0.70-1.52, P = .83) (interaction P = .24). The results were similar when the effect of PCI was assessed in patients with proximal LAD occlusion. CONCLUSIONS: In stable patients, persistent total occlusion of the LAD post MI is associated with a worse prognosis compared with occlusion of the other IRAs. A strategy of PCI of occluded LAD IRA >24 hours post MI in stable patients is not beneficial and may increase risk of adverse events in comparison to optimal medical treatment alone
— id: 101571, year: 2009, vol: 157, page: 724, stat: Journal Article,

Quality of life after late invasive therapy for occluded arteries
Mark, Daniel B; Pan, Wenqin; Clapp-Channing, Nancy E; Anstrom, Kevin J; Ross, John R; Fox, Rebecca S; Devlin, Gerard P; Martin, C Edwin; Adlbrecht, Christopher; Cowper, Patricia A; Ray, Linda Davidson; Cohen, Eric A; Lamas, Gervasio A; Hochman, Judith S
2009 Feb 19;360(8):774-783, New England journal of medicine
BACKGROUND: The open-artery hypothesis postulates that late opening of an infarct-related artery after myocardial infarction will improve clinical outcomes. We evaluated the quality-of-life and economic outcomes associated with the use of this strategy. METHODS: We compared percutaneous coronary intervention (PCI) plus stenting with medical therapy alone in high-risk patients in stable condition who had a totally occluded infarct-related artery 3 to 28 days after myocardial infarction. In 951 patients (44% of those eligible), we assessed quality of life by means of a battery of tests that included two principal outcome measures, the Duke Activity Status Index (DASI) (which measures cardiac physical function on a scale from 0 to 58, with higher scores indicating better function) and the Medical Outcomes Study 36-Item Short-Form Mental Health Inventory 5 (which measures psychological well-being). Structured quality-of-life interviews were performed at baseline and at 4, 12, and 24 months. Costs of treatment were assessed for 458 of 469 patients in the United States (98%), and 2-year cost-effectiveness was estimated. RESULTS: At 4 months, the medical-therapy group, as compared with the PCI group, had a clinically marginal decrease of 3.4 points in the DASI score (P=0.007). At 1 and 2 years, the differences were smaller. No significant differences in psychological well-being were observed. For the 469 patients in the United States, cumulative 2-year costs were approximately $7,000 higher in the PCI group (P<0.001), and the quality-adjusted survival was marginally longer in the medical-therapy group. CONCLUSIONS: PCI was associated with a marginal advantage in cardiac physical function at 4 months but not thereafter. At 2 years, medical therapy remained significantly less expensive than routine PCI and was associated with marginally longer quality-adjusted survival. (ClinicalTrials.gov number, NCT00004562.)
— id: 96631, year: 2009, vol: 360, page: 774, stat: Journal Article,

Incidence of and outcomes associated with ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention
Mehta, Rajendra H; Starr, Aijing Z; Lopes, Renato D; Hochman, Judith S; Widimsky, Petr; Pieper, Karen S; Armstrong, Paul W; Granger, Christopher B
2009 May 6;301(17):1779-1789, JAMA
CONTEXT: The incidence and timing of sustained ventricular tachycardia or fibrillation (VT/VF) and its impact on outcomes in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) are poorly understood. OBJECTIVE: To evaluate the association of sustained VT/VF and its timing on the outcomes of patients presenting for primary PCI-an aim not prespecified in the APEX AMI trial. DESIGN, SETTING, AND PATIENTS: We studied 5745 STEMI patients presenting for primary PCI at 296 hospitals in 17 countries between July 13, 2004, and May 11, 2006, from the APEX AMI trial. We categorized them into 4 groups: no VT/VF; VT/VF any time; early VT/VF, before the end of cardiac catheterization; and late VT/VF, after the end of cardiac catheterization. MAIN OUTCOME MEASURE: Ninety-day total mortality. RESULTS: VT/VF occurred in 329 STEMI patients (5.7%) presenting for primary PCI. The majority of these occurred before the end of catheterization (n = 205, 64%), and 90% occurred within 48 hours of presentation with symptoms of STEMI. Clinical outcomes were worse in patients with vs those without VT/VF (90-day mortality, 23.2% vs 3.6%; adjusted HR, 3.63; 95% CI, 2.59-5.09), and outcomes were worse if the VT/VF occurred late instead of early (90-day mortality for early VT/VF, 17.2% [adjusted HR, 2.34; 95% CI, 1.44-3.80]; for late VT/VF, 33.3% [adjusted HR, 5.59; 95% CI, 3.71-8.43]; for no VT/VF, 3.6% [referent]). In multivariate analyses, factors associated with early VT/VF included pre-PCI thrombolysis in MI (TIMI) flow grade 0 (HR, 2.94; 95% CI, 1.93-4.47), inferior infarction (HR, 2.16; 95% CI, 1.58-2.93), total baseline ST deviation (HR, 1.39; 95% CI, 1.19-1.63), creatinine clearance (HR, 0.88; 95% CI, 0.83-0.94), Killip class greater than I (HR, 1.88; 95% CI, 1.29-2.76), baseline systolic blood pressure (HR, 0.92; 95% CI, 0.87-0.98), body weight (HR, 1.16; 95% CI, 1.04-1.29), and baseline heart rate greater than 70/min (HR, 1.10; 95% CI, 1.01-1.20) (c index, 0.75). Factors related to late VT/VF were systolic blood pressure (HR, 0.83; 95% CI, 0.76-0.91), ST resolution less than 70% (HR, 3.17; 95% CI, 1.60-6.28), baseline heart rate greater than 70/min (HR, 1.20; 95% CI, 1.08-1.33), total baseline ST deviation (HR, 1.43; 95% CI, 1.14-1.79), post-PCI TIMI flow less than grade 3 (HR, 2.09; 95% CI, 1.24-3.52), pre-PCI TIMI flow grade 0 (HR, 2.12; 95% CI, 1.20-3.75), and beta-blockers less than 24 hours (HR, 0.52; 95% CI, 0.32-0.85) (c index, 0.74). CONCLUSIONS: In this study, occurrence of VT/VF before or after the end of cardiac catheterization in patients presenting for primary PCI was associated with increased 90-day mortality
— id: 101570, year: 2009, vol: 301, page: 1779, stat: Journal Article,

Failure to timely identify the posterior circulation infarct related artery: Observations from the occluded artery trial
Menon V.; Carvalho A.C.; Thuaire C.; Forman S.A.; Sousa J.M.A.; Jaworska K.; Turgeman Y.; Lamas G.A.; Hochman J.S.
2009 ;30:620-620, European heart journal
Background: Reperfusion therapy is guided by ST elevations on the EKG. The Occluded Artery Trial (OAT) identified stable patients with persistent late occlusion of the infarct related artery (IRA) on days 3-28 (minimum 24 hours) post MI. We hypothesized that insensitivity of the EKG in the posterior circulation would result in overrepresentation of circumflex IRA in patients with NSTEMI/NQMI. Methods: We compared IRA distribution, baseline characteristics and outcomes for 285 patients in OAT with no ST elevation/Q waves/loss of R wave voltage or new LBBB (NSTEMI/Non Q) compared to 1916 subjects with STEMI/Q/new LBBB (STEMI). Results: As hypothesized circumflex IRA was overrepresented in the NSTEMI/NQMI group (table). The 60-month outcome for NSTEMI/NQMI patients randomized to PCI vs. optimal medical therapy were similar: composite of Death, MI and Class IV HF (17.6 vs. 16.3%, p=0.70, HR 1.13; 0.50-2.55); Death (11.6 vs. 14.5%, p=0.46, HR 0.75; 0.27-2.06); MI (4.6 vs. 5.0%, p=0.88, HR 0.91; 0.19- 4.33); Class IV CHF (5.2 vs. 3.9%, p=0.45, HR 1.56; 0.35-7.06) and there was no interaction between MI type and treatment effect (p=NS). (Table presented). Conclusion: In OAT there was no difference in the effect of PCI based on infarct type on EKG. The circumflex IRA represents a minority in the STEMI group but constitutes 43% of the NSTEMI/Non Q population. Our observation highlights our inability to acutely identify occluded posterior circulation IRA. Efforts to do so will increase the population benefiting from optimal reperfusion (0-12 hours post MI)
— id: 126522, year: 2009, vol: 30, page: 620, stat: Journal Article,

Lack of benefit from percutaneous intervention of persistently occluded infarct arteries after the acute phase of myocardial infarction is time independent: insights from Occluded Artery Trial
Menon, Venu; Pearte, Camille A; Buller, Christopher E; Steg, Ph Gabriel; Forman, Sandra A; White, Harvey D; Marino, Paolo N; Katritsis, Demosthenes G; Caramori, Paulo; Lasevitch, Ricardo; Loboz-Grudzien, Krystyna; Zurakowski, Aleksander; Lamas, Gervasio A; Hochman, Judith S
2009 Jan;30(2):183-191, European heart journal
AIMS: The Occluded Artery Trial (OAT) (n = 2201) showed no benefit for routine percutaneous intervention (PCI) (n = 1101) over medical therapy (MED) (n = 1100) on the combined endpoint of death, myocardial infarction (MI), and class IV heart failure (congestive heart failure) in stable post-MI patients with late occluded infarct-related arteries (IRAs). We evaluated the potential for selective benefit with PCI over MED for patients enrolled early in OAT. METHODS AND RESULTS: We explored outcomes with PCI over MED in patients randomized to the </=3 calendar days and </=7 calendar days post-MI time windows. Earlier, times to randomization in OAT were associated with higher rates of the combined endpoint (adjusted HR 1.04/day: 99% CI 1.01-1.06; P < 0.001). The 48-month event rates for </=3 days, </=7 days post-MI enrolled patients were similar for PCI vs. MED for the combined and individual endpoints. There was no interaction between time to randomization defined as a continuous (P = 0.55) or categorical variable with a cut-point of 3 days (P = 0.98) or 7 days (P = 0.64) post-MI and treatment effect. CONCLUSION: Consistent with overall OAT findings, patients enrolled in the </=3 day and </=7 day post-MI time windows derived no benefit with PCI over MED with no interaction between time to randomization and treatment effect. Our findings do not support routine PCI of the occluded IRA in trial-eligible patients even in the earliest 24-72 h time window
— id: 96633, year: 2009, vol: 30, page: 183, stat: Journal Article,

Electrophysiological effects of late percutaneous coronary intervention for infarct-related coronary artery occlusion: the Occluded Artery Trial-Electrophysiological Mechanisms (OAT-EP)
Rashba, Eric J; Lamas, Gervasio A; Couderc, Jean-Philippe; Hollist, Sharri M; Dzavik, Vladimir; Ruzyllo, Witold; Fridrich, Viliam; Buller, Christopher E; Forman, Sandra A; Kufera, Joseph A; Carvalho, Antonio C; Hochman, Judith S
2009 Feb 17;119(6):779-787, Circulation
BACKGROUND: The Occluded Artery Trial-Electrophysiological Mechanisms (OAT-EP) tested the hypothesis that opening a persistently occluded infarct-related artery by percutaneous coronary intervention and stenting (PCI) after the acute phase of myocardial infarction compared with optimal medical therapy alone reduces markers of vulnerability to ventricular arrhythmias. METHODS AND RESULTS: Between April 2003 and December 2005, 300 patients with an occluded native infarct-related artery 3 to 28 days (median, 12 days) after myocardial infarction were randomized to PCI or optimal medical therapy. Ten-minute digital Holter recordings were obtained before randomization, at 30 days, and at 1 year. The primary end point was the change in alpha1, a nonlinear heart rate variability parameter, between baseline and 1 year. Major secondary end points were the changes in the filtered QRS duration on the signal-averaged ECG and variability in T-wave morphology (T-wave variability) between baseline and 1 year. There were no significant differences in the changes in alpha1 (-0.04; 95% CI, -0.12 to 0.04), filtered QRS (2.2 ms; 95% CI, -1.4 to 5.9 ms), or T-wave variability (3.0 microV; 95% CI, -4.8 to 10.7 microV) between the PCI and medical therapy groups (medical therapy change minus PCI change). Multivariable analysis revealed that the results were unchanged after adjustment for baseline clinical variables and medication treatments during the Holter recordings. CONCLUSIONS: PCI with stenting of a persistently occluded infarct-related artery during the subacute phase after myocardial infarction compared with medical therapy alone had no significant effect on changes in heart rate variability, the time-domain signal-averaged ECG, or T-wave variability during the first year after myocardial infarction. These findings are consistent with the lack of clinical benefit, including no reduction in sudden death, with PCI for stable patients with persistently occluded infarct-related arteries after myocardial infarction in the main OAT
— id: 96632, year: 2009, vol: 119, page: 779, stat: Journal Article,

Age and Outcomes After Myocardial Infarction With Persistent Total Occlusion of the Infarct Related Artery: An Analysis of the Occluded Artery Trial
Skolnick, AH; Dzavik, V; Menon, V; Liu, L; Maggioni, AP; Carvalho, AC; Gruberg, L; Eduardo, R; Azevedo, U; Schroeder, E; Pearte, CA; White, HD; Lamas, GA; Hochman, JS
2009 MAR 10 ;53(10):A326-A326, Journal of the American College of Cardiology
— id: 97557, year: 2009, vol: 53, page: A326, stat: Journal Article,

Extent and Severity of Coronary Stenosis at Autopsy Varies by Sex in Fatal Cases of Coronary Heart Disease
Smilowitz, N; Hochman, JS; Sampson, BA; Mangalmurti, S; Siegfried, J; Reynolds, HR
2009 NOV 3 ;120(18):S1049-S1049, Circulation
— id: 106982, year: 2009, vol: 120, page: S1049, stat: Journal Article,

2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee
Antman, Elliott M; Hand, Mary; Armstrong, Paul W; Bates, Eric R; Green, Lee A; Halasyamani, Lakshmi K; Hochman, Judith S; Krumholz, Harlan M; Lamas, Gervasio A; Mullany, Charles J; Pearle, David L; Sloan, Michael A; Smith, Sidney C Jr; Anbe, Daniel T; Kushner, Frederick G; Ornato, Joseph P; Jacobs, Alice K; Adams, Cynthia D; Anderson, Jeffrey L; Buller, Christopher E; Creager, Mark A; Ettinger, Steven M; Halperin, Jonathan L; Hunt, Sharon A; Lytle, Bruce W; Nishimura, Rick; Page, Richard L; Riegel, Barbara; Tarkington, Lynn G; Yancy, Clyde W
2008 Jan 15;117(2):296-329, Circulation
— id: 96638, year: 2008, vol: 117, page: 296, stat: Journal Article,

2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Antman, Elliott M; Hand, Mary; Armstrong, Paul W; Bates, Eric R; Green, Lee A; Halasyamani, Lakshmi K; Hochman, Judith S; Krumholz, Harlan M; Lamas, Gervasio A; Mullany, Charles J; Pearle, David L; Sloan, Michael A; Smith, Sidney C Jr; Anbe, Daniel T; Kushner, Frederick G; Ornato, Joseph P; Pearle, David L; Sloan, Michael A; Jacobs, Alice K; Adams, Cynthia D; Anderson, Jeffrey L; Buller, Christopher E; Creager, Mark A; Ettinger, Steven M; Halperin, Jonathan L; Hunt, Sharon A; Lytle, Bruce W; Nishimura, Rick; Page, Richard L; Riegel, Barbara; Tarkington, Lynn G; Yancy, Clyde W
2008 Jan 15;51(2):210-247, Journal of the American College of Cardiology
— id: 96637, year: 2008, vol: 51, page: 210, stat: Journal Article,

Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock
Apolito, Renato A; Greenberg, Mark A; Menegus, Mark A; Lowe, April M; Sleeper, Lynn A; Goldberger, Mark H; Remick, Joshua; Radford, Martha J; Hochman, Judith S
2008 Feb;155(2):267-273, American heart journal
BACKGROUND: Studies suggest that the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System, which makes public the operator-specific mortality for patients undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI), may deter operators from providing revascularization to high-risk cardiac patients in New York compared to other states. METHODS: We performed a retrospective analysis of 545 US patients with acute myocardial infarction and cardiogenic shock due to predominant left ventricular failure enrolled in the SHOCK Registry. Adjusting for case mix using a propensity score method, we compared the use of coronary angiography, PCI, CABG, and outcomes between 220 patients in New York and 325 in other states. RESULTS: New York patients were older with similar or less severe baseline characteristics. After propensity score adjustment, New York patients were less likely than non-New York patients to undergo coronary angiography (odds ratio 0.46, 95% CI 0.31-0.68, P < .001) and PCI (odds ratio 0.51, 95% CI 0.33-0.77, P = .002). Coronary artery bypass graft rates were similarly low (14.1% vs 15.1%, P = not significant), but New York patients waited significantly longer after shock onset for surgery (101.2 vs 10.3 hours, P < .001) with only 32.3% of New York patients vs 75.5% of non-New York patients (P < .001) taken for CABG within 3 days of shock onset. CONCLUSIONS: In our propensity-adjusted retrospective analysis, New York patients with acute myocardial infarction and cardiogenic shock were less likely to undergo coronary angiography and PCI and waited significantly longer to receive CABG than their non-New York counterparts. These findings suggest that state-required reporting to the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System may result in the reluctance to revascularize the highest-risk cardiac patients
— id: 76090, year: 2008, vol: 155, page: 267, stat: Journal Article,

Impact of stress testing prior to PCI or medical management on outcomes of patients with persistent total occlusion after myocardial infarction: analysis from the occluded artery trial (OAT)
Cantor, WJ; Lamas, GA; Nikolsky, E; Pearte, CA; Srinivas, VS; Forman, SA; Menon, V; Ross, JR; Baptista, SB; Meciar, P; Sadowski, Z; Hochman, JS
2008 MAR 11 ;51(10):A191-A191, Journal of the American College of Cardiology
— id: 78381, year: 2008, vol: 51, page: A191, stat: Journal Article,

Sex and race are associated with the finding of non-obstructive coronary artery disease in patients with acute coronary syndromes
Chokshi, NP; Berger, RL; Hochman, JS; Keller, NM; Feit, F; Attubato, MJ; Slater, JN; Pena-Sing, I; Babaev, A; Reynolds, HR
2008 MAR 11 ;51(10):A217-A217, Journal of the American College of Cardiology
— id: 78384, year: 2008, vol: 51, page: A217, stat: Journal Article,

Routine PCI improves short but not long term angina status in patients with an occluded infarct artery: Results from the occluded artery trial (OAT)
Devlin, GP; Mark, DB; Lamas, GA; Carvalho, AC; Dzavik, V; Forman, SA; Vozzi, CR; Ragosta, M; Rankin, JM; Caramori, P; Sopko, G; Balcells, E; Leor, J; Barton, BA; Hochman, JS
2008 MAR 11 ;51(10):A222-A223, Journal of the American College of Cardiology
— id: 78385, year: 2008, vol: 51, page: A222, stat: Journal Article,

A meta-analysis that misses the mark
Dzavik, Vladimir; Steg, P Gabriel; Barton, Bruce; Lamas, Gervasio; Hochman, Judith S
2008 Aug 12;52(7):578-580, Journal of the American College of Cardiology
— id: 96635, year: 2008, vol: 52, page: 578, stat: Journal Article,

Distribution and determinants of myocardial perfusion grade following late mechanical recanalization of occluded infarct-related arteries postmyocardial infarction: a report from the occluded artery trial
Jorapur, Vinod; Steigen, Terje K; Buller, Christopher E; Dzavik, Vladimir; Webb, John G; Strauss, Bradley H; Yeoh, Eunice E S; Kurray, Peter; Sokalski, Leszek; Machado, Mauricio C; Kronsberg, Shari S; Lamas, Gervasio A; Hochman, Judith S; Mancini, G B John
2008 Nov 15;72(6):783-789, Catheterization & cardiovascular interventions
OBJECTIVE: To evaluate the distribution and determinants of myocardial perfusion grade (MPG) following late recanalization of persistently occluded infarct-related arteries (IRA). BACKGROUND: MPG reflects microvascular integrity. It is an independent prognostic factor following myocardial infarction, but has been studied mainly in the setting of early reperfusion. The occluded artery trial (OAT) enrolled stable patients with persistently occluded IRAs beyond 24 hr and up to 28 days post-MI. METHODS: Myocardial blush was assessed using TIMI MPG grading in 261 patients with TIMI 3 epicardial flow following IRA PCI. Patients demonstrating impaired (0-1) versus preserved (2-3) MPG were compared with regard to baseline clinical and pre-PCI angiographic characteristics. RESULTS: Impaired MPG was observed in 60 of 261 patients (23%). By univariate analysis, impaired MPG was associated with failed fibrinolytic therapy, higher heart rate, lower systolic blood pressure, lower ejection fraction, LAD occlusion, absence of collaterals (P < 0.01) and ST elevation MI, lower diastolic blood pressure, and higher systolic sphericity index (P < 0.05). By multivariable analysis, higher heart rate, LAD occlusion, absence of collaterals and higher systolic sphericity index (P < 0.01), and lower systolic blood pressure (P < 0.05) were independently associated with impaired MPG. CONCLUSION: Preserved microvascular integrity was present in a high proportion of patients following late recanalization of occluded IRAs post-MI. Presence of collaterals was independently associated with preserved MPG and likely accounted for the high frequency of preserved myocardial perfusion in this clinical setting. Impaired MPG was associated with baseline clinical and angiographic features consistent with larger infarct size
— id: 96634, year: 2008, vol: 72, page: 783, stat: Journal Article,

Predictors of Outcome and the Lack of Effect of Percutaneous Coronary Intervention Across the Risk Strata in Patients With Persistent Total Occlusion After Myocardial Infarction. Results From the Occluded Artery Trial (OAT)
Kruk, Mariusz; Kadziela, Jacek; Reynolds, Harmony R; Forman, Sandra A; Sadowski, Zygmunt; Barton, Bruce A; Mark, Daniel B; Maggioni, Aldo P; Leor, Jonathan; Webb, John G; Kapeliovich, Michael; Marin-Neto, Jose A; White, Harvey D; Lamas, Gervasio A; Hochman, Judith S
2008 ;1:511-520, JACC: Cardiovascular Interventions
OBJECTIVES: To determine predictors of outcome and examine the influence of baseline risk on therapeutic impact of late mechanical opening of a persistently occluded infarct related artery (IRA) after myocardial infarction (MI) in stable patients. BACKGROUND: Previous studies in patients with acute coronary syndromes suggest that the impact of IRA recanalization on clinical outcome is greatest in patients at highest risk. METHODS: Of 2201 patients (age 58.6+/-11.0) with IRA occlusion on days 3 to 28 after MI in the Occluded Artery Trial (OAT), 1101 were assigned to PCI and 1100 to medical therapy alone, and followed for a mean of 3.2 years. The primary end point was a composite of death, reinfarction, or NYHA class IV heart failure. Interaction of treatment effect with tertiles of predicted survival were examined using the Cox survival model. RESULTS: The 5-year rate for the primary endpoint was 18.9% versus 16.1% for patients assigned PCI and medical treatment alone (MED) respectively (HR=1.14;95% CI:0.92-1.43, p=0.23). Lack of benefit of PCI was consistent across the risk spectrum for both the primary endpoint and total mortality, including for the highest tertile (33.9% PCI versus 27.3 % MED, HR=1.27;99% CI:0.87-1.85 primary endpoint and 23.5% PCI versus 21.7% MED, HR=1.16,99% CI: 0.73-1.85 mortality). The independent predictors of the composite outcome were: history of heart failure (HR=2.06,p<0.001), peripheral vascular disease (HR=1.93,p=0.001), diabetes (HR=1.49,p=0.002), rales (HR=1.88,p<0.001), decreasing: ejection fraction (HR=1.48 per 10%,p<0.001), days from MI to randomization (HR=1.04 per day,p<0.001), and glomerular filtration rate (HR=1.11 per 10mL/min/1.73m(2),p<0.001). CONCLUSIONS: In OAT, there was no variation in the effect of PCI on clinical outcomes at different levels of patient risk, including the subset with very high event rates
— id: 94437, year: 2008, vol: 1, page: 511, stat: Journal Article,

Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease
Lee, Michael S; Tseng, Chi-Hong; Barker, Colin M; Menon, Venu; Steckman, David; Shemin, Richard; Hochman, Judith S
2008 Jul;86(1):29-34, Annals of thoracic surgery
BACKGROUND: The ideal revascularization strategy (bypass surgery versus percutaneous coronary intervention [PCI]) for patients with cardiogenic shock in the setting of left main coronary artery disease is unknown. METHODS: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock Trial and Registry included 164 patients with left main disease who underwent revascularization. Although the standard of care at the time and the trial protocol recommended coronary artery bypass graft surgery for patients with left main disease, the revascularization strategy (79 coronary artery bypass graft surgery and 85 PCI) was individualized for each patient by site investigators. RESULTS: The median time from myocardial infarction to revascularization was 24.3 hours (interquartile range, 8.7 to 82.5 hours) in the surgical group and 7.4 hours (interquartile range, 3.7 to 19.5 hours) in the PCI group (p < 0.05). Overall 30-day survival with surgery in this setting was 54% (95% confidence interval, 0.43 to 0.69) and was significantly superior to the 14% (95% confidence interval, 0.09 to 0.35) in the PCI group (p <or= 0.001). When the left main was the infarct-related artery, the 30-day survival rate was 40% in the surgical group (n = 6) and 16% in the PCI group (n = 15; p = 0.03). Coronary artery bypass graft surgery (hazard ratio, 0.41; 95% confidence interval, 0.22 to 0.77; p = 0.006) and age (per 10 years, hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.08; p = 0.02) were independently associated with 30-day survival. CONCLUSIONS: Coronary artery bypass graft surgery appeared to provide a survival advantage over PCI at 30-day follow-up in patients with left main coronary artery disease. The impact of current PCI strategies on this subgroup is undetermined
— id: 96636, year: 2008, vol: 86, page: 29, stat: Journal Article,

Lack of benefit with PCI for total occlusions in stable patients following myocardial infarction is time independent: Results from the Occluded Artery Trial (OAT)
Menon, V; Pearte, CA; Buller, CE; Stag, PG; Forman, SA; White, HD; Marino, PN; Katritsis, DG; Caramon, P; Lasevitch, R; Loboz-Grudzien, K; Zuralkowski, A; Lamas, GA; Hochman, JS
2008 MAR 11 ;51(10):A201-A201, Journal of the American College of Cardiology
— id: 78382, year: 2008, vol: 51, page: A201, stat: Journal Article,

Response to letter regarding article, "Metabolic Profiling of Arginine and Nitric Oxide Pathways Predicts Hemodynamic Abnormalities and Mortality in Patients With Cardiogenic Shock After Acute Myocardial Infarct"
Nicholls, SJ; Nissen, SE; Hazen, SL; Wang, Z; Koeth, R; Levison, B; DelFraino, B; Dzavik, V; Griffith, OW; Hathaway, D; Panza, JA; Hochman, JS
2008 SEP 2 ;118(10):E150-E150, Circulation
— id: 86804, year: 2008, vol: 118, page: E150, stat: Journal Article,

Cardiogenic shock: current concepts and improving outcomes
Reynolds, Harmony R; Hochman, Judith S
2008 Feb 5;117(5):686-697, Circulation
— id: 76106, year: 2008, vol: 117, page: 686, stat: Journal Article,

Collateral flow to the occluded infarct-related artery is associated with a lower rate of heart failure in the occluded artery trial (OAT)
Steg, PG; Kerner, A; Buller, CE; Forman, SA; White, HD; Carvalho, AC; Reynolds, HR; Fricrich, V; Cohen, EA; Mancini, GBJ; Lamas, GA; Hochman, JS
2008 MAR 11 ;51(10):A215-A215, Journal of the American College of Cardiology
— id: 78383, year: 2008, vol: 51, page: A215, stat: Journal Article,

Long-term outcomes in non-diabetic patients with metabolic syndrome undergoing revascularization for multi-vessel coronary artery disease
Yatskar, Leonid; Holper, Elizabeth; Bansilal, Sameer; Schwartzbard, Arthur; Lombardero, Manuel; Ramanathan, Krishnan; Feit, Frederick; Fisher, Edward; Faxon, David; Hochman, Judith S; Farkouh, Michael E
2008 Jun;198(2):389-395, Atherosclerosis
AIM: The influence of metabolic syndrome (MS) on long-term mortality and morbidity in multi-vessel coronary artery disease (MV-CAD) is unclear. We studied the impact of MS on long-term outcomes in non-diabetic patients (NDM) with MV-CAD undergoing coronary revascularization in the Bypass Angioplasty Revascularization Investigation (BARI) trial and registry. METHODS: BARI trial and registry patients were separated into those with diabetes (DM) and those without. NDM fulfilling the NCEP definition of MS were identified. Ten year follow-up data were obtained on mortality, MI and development of diabetes. The data were analyzed using Cox proportional hazard modeling. RESULTS: In the BARI trial and registry 2962 NDM were identified. Of those, 510 patients had 3 or more components of the BARI-modified NCEP definition for MS, while 445 patients had 2 components of the definition and were classified as the 'mixed group'. Compared to patients without MS, both MS group (RR=3.2, p<0.0001) and the mixed group (RR=1.9, p=0.02) had a higher incidence of DM over the 10-year follow-up. Type 2 DM was found to be highly associated with 10-year mortality (RR=1.65, p<0.0001). However, there was no statistically significant difference in the rate of death or MI at 5 and 10 years between NDM with or without MS. In multivariate analysis, the presence of MS was not associated with 10-year mortality in the BARI population (RR=0.93, p=0.62). CONCLUSION: In this BARI follow-up study, we have affirmed the role of MS in predicting the development of diabetes in NDM at baseline. The 10-year risk of mortality and MI was not greater in NDM with MS who had MV-CAD and underwent revascularization, compared to patients without MS. Further studies to evaluate MS patients with MV-CAD undergoing coronary revascularization are warranted
— id: 79378, year: 2008, vol: 198, page: 389, stat: Journal Article,

Effect of tilarginine acetate in patients with acute myocardial infarction and cardiogenic shock: the TRIUMPH randomized controlled trial
Alexander, John H; Reynolds, Harmony R; Stebbins, Amanda L; Dzavik, Vladimir; Harrington, Robert A; Van de Werf, Frans; Hochman, Judith S
2007 Apr 18;297(15):1657-1666, JAMA
CONTEXT: Cardiogenic shock complicating acute myocardial infarction (MI) remains a common and lethal disorder despite aggressive use of early revascularization. Systemic inflammation, including expression of inducible nitric oxide synthase (NOS) and generation of excess nitric oxide, is believed to contribute to the pathogenesis and inappropriate vasodilatation of persistent cardiogenic shock. Preliminary, single-center studies suggested a beneficial effect of NOS inhibition on hemodynamics, renal function, and survival in patients with cardiogenic shock. OBJECTIVE: To examine the effects of an isoform-nonselective NOS inhibitor in patients with MI and refractory cardiogenic shock despite establishment of an open infarct artery. DESIGN, SETTING, AND PATIENTS: International, multicenter, randomized, double-blind, placebo-controlled trial (Tilarginine Acetate Injection in a Randomized International Study in Unstable MI Patients With Cardiogenic Shock [TRIUMPH]) with planned enrollment of 658 patients at 130 centers. Participants were enrolled between January 2005 and August 2006 when the study was terminated early. INTERVENTION: Tilarginine (L-N(G)-monomethylarginine [L-NMMA]), 1-mg/kg bolus and 1-mg/kg per hour 5-hour infusion, vs matching placebo. MAIN OUTCOME MEASURES: The primary outcome was 30-day all-cause mortality among patients who received study medication. Secondary outcomes included shock resolution and duration, New York Heart Association (NYHA) functional class at 30 days, and 6-month mortality. RESULTS: Enrollment was terminated at 398 patients based on a prespecified futility analysis. Six-month follow-up was completed in February 2007. There was no difference in 30-day all-cause mortality between patients who received tilarginine (97/201 [48%]) vs placebo (76/180 [42%]) (risk ratio, 1.14; 95% confidence interval, 0.92-1.41; P = .24). Resolution of shock (133/201 [66%] tilarginine vs 110/180 [61%] placebo; P = .31) and duration of shock (median, 156 [interquartile range, 78-759] hours tilarginine vs 190 [100-759] placebo; P = .16) were similar. At 30 days a similar percentage of patients had heart failure (48% tilarginine vs 51% placebo; P = .51) with a similar percentage of those patients in NYHA class I/II (73% tilarginine vs 75% placebo; P = .27). After 6 months mortality rates were similar in the 2 groups (58% tilarginine vs 59% placebo; hazard ratio, 1.04; 95% confidence interval, 0.79-1.36; P = .80). CONCLUSIONS: Tilarginine, 1-mg/kg bolus and 5-hour infusion, did not reduce mortality rates in patients with refractory cardiogenic shock complicating MI despite an open infarct artery. Early mortality rates in this patient group are high. Further research is needed to develop effective therapies for patients with cardiogenic shock following acute MI. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00112281
— id: 71980, year: 2007, vol: 297, page: 1657, stat: Journal Article,

ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
Anderson, Jeffrey L; Adams, Cynthia D; Antman, Elliott M; Bridges, Charles R; Califf, Robert M; Casey, Donald E Jr; Chavey, William E 2nd; Fesmire, Francis M; Hochman, Judith S; Levin, Thomas N; Lincoff, A Michael; Peterson, Eric D; Theroux, Pierre; Wenger, Nanette Kass; Wright, R Scott; Smith, Sidney C Jr; Jacobs, Alice K; Adams, Cynthia D; Anderson, Jeffrey L; Antman, Elliott M; Halperin, Jonathan L; Hunt, Sharon A; Krumholz, Harlan M; Kushner, Frederick G; Lytle, Bruce W; Nishimura, Rick; Ornato, Joseph P; Page, Richard L; Riegel, Barbara
2007 Aug 14;50(7):e1-e157, Journal of the American College of Cardiology
— id: 96643, year: 2007, vol: 50, page: e1, stat: Journal Article,

ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
Anderson, Jeffrey L; Adams, Cynthia D; Antman, Elliott M; Bridges, Charles R; Califf, Robert M; Casey, Donald E Jr; Chavey, William E 2nd; Fesmire, Francis M; Hochman, Judith S; Levin, Thomas N; Lincoff, A Michael; Peterson, Eric D; Theroux, Pierre; Wenger, Nanette Kass; Wright, R Scott; Smith, Sidney C Jr; Jacobs, Alice K; Halperin, Jonathan L; Hunt, Sharon A; Krumholz, Harlan M; Kushner, Frederick G; Lytle, Bruce W; Nishimura, Rick; Ornato, Joseph P; Page, Richard L; Riegel, Barbara
2007 Aug 14;116(7):e148-e304, Circulation
— id: 96644, year: 2007, vol: 116, page: e148, stat: Journal Article,

Challenging coronary artery revascularization paradigms
Bates, Eric R; Hochman, Judith S
2007 Dec;154(6):1005-1007, American heart journal
— id: 96639, year: 2007, vol: 154, page: 1005, stat: Journal Article,

Heart Failure With Preserved Left Ventricular Systolic Function Among Patients With Non-ST-Segment Elevation Acute Coronary Syndromes
Bennett, Kyla M; Hernandez, Adrian F; Chen, Anita Y; Mulgund, Jyotsna; Newby, L Kristin; Rumsfeld, John S; Hochman, Judith S; Hoekstra, James W; Ohman, E Magnus; Gibler, W Brian; Roe, Matthew T; Peterson, Eric D
2007 May 15;99(10):1351-1356, American journal of cardiology
Previous studies of non-ST-segment elevation acute coronary syndromes (NSTE ACSs) complicated by heart failure (HF) have focused primarily on patients with left ventricular systolic dysfunction defined by an ejection fraction (EF) <40%. Little is known about HF with preserved systolic function (EF >/=40%) in the NSTE ACS population. We identified high-risk patients with NSTE ACS (ischemic electrocardiographic changes and/or positive cardiac markers) from the CRUSADE quality improvement initiative who had an EF recorded and who had information on HF status. Management and outcomes were analyzed and compared based on the presence or absence of HF and whether left ventricular EF was >/=40%. Of 94,558 patients with NSTE ACS, 21,561 (22.8%) presented with signs of HF, and most had HF with preserved systolic function (n = 11,860, 55%). Mortality rates were 10.7% for HF/systolic dysfunction, 5.8% for HF/preserved systolic function, 5.7% for no HF/systolic dysfunction, and 1.5% for no HF/preserved systolic function. Use of guideline-recommended medical therapies and interventions was frequently significantly lower in those with HF regardless of EF compared with those without HF, except for use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In conclusion, NSTE ACS complicated by HF with preserved systolic function is common and associated with a 2.3-fold higher mortality compared with NSTE ACS without HF or systolic dysfunction. Guideline-recommended therapies and interventions are under-utilized in patients with NSTE ACS and HF, with and without preserved systolic function, compared with those without HF
— id: 71976, year: 2007, vol: 99, page: 1351, stat: Journal Article,

Similar long-term outcomes after PCI success, PCI failure, and no PCI in the occluded artery trial (OAT)
Buller, CE; Dzavik, V; Forman, SA; Ruzyllo, W; Buszman, PE; Michalis, LK; Mancini, GBJ; Renkin, J; Pfisterer, ME; Thomas, B; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):525-526, Circulation
— id: 75974, year: 2007, vol: 116, page: 525, stat: Journal Article,

PCI failure in the Occluded Artery Trial (OAT): Frequency, mechanisms, and outcome
Buller, CE; Mancini, J; Dzavik, V; Pfisterer, ME; Rankin, JM; Carere, RG; Michalis, LK; Renkin, J; Forman, SA; Abreu, PF; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):416-416, Circulation
— id: 75971, year: 2007, vol: 116, page: 416, stat: Journal Article,

Did early hazard of PCI offset late benefit in the occluded artery trial (OAT)?
Buller, CE; Rankin, JM; Renkin, J; Carere, RG; Dzavik, V; Ruzyllo, W; Forman, SA; Buszman, PE; Mancini, GBJ; Abreu, PF; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):667-667, Circulation
— id: 75981, year: 2007, vol: 116, page: 667, stat: Journal Article,

Effect of nitric oxide synthase inhibition on haemodynamics and outcome of patients with persistent cardiogenic shock complicating acute myocardial infarction: a phase II dose-ranging study
Dzavik, Vladimir; Cotter, Gad; Reynolds, Harmony R; Alexander, John H; Ramanathan, Krishnan; Stebbins, Amanda L; Hathaway, David; Farkouh, Michael E; Ohman, E Magnus; Baran, David A; Prondzinsky, Roland; Panza, Julio A; Cantor, Warren J; Vered, Zvi; Buller, Christopher E; Kleiman, Neal S; Webb, John G; Holmes, David R; Parrillo, Joseph E; Hazen, Stanley L; Gross, Steven S; Harrington, Robert A; Hochman, Judith S
2007 May;28(9):1109-1116, European heart journal
Aims Previous studies suggested haemodynamic benefits and, possibly, mortality reduction with the use of nitric oxide synthase (NOS) inhibition in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). We assessed preliminary efficacy and safety of four doses of l-n-monomethyl-arginine (l-NMMA), a non-selective NOS inhibitor, in patients with AMI complicated by CS despite an open infarct-related artery. Methods and results Patients (n = 79) were randomly assigned to a bolus and 5 h infusion of placebo or 0.15, 0.5, 1.0, or 1.5 mg/kg of l-NMMA. The primary outcome measure was absolute change in mean arterial pressure (MAP) at 2 h. Fifteen minutes after study drug initiation, mean change in MAP was -4.0 mmHg in the placebo group and 5.8 (P = 0.02), 4.8 (P = 0.02), 5.1 (P = 0.07), and 11.6 (P < 0.001) mmHg in the four l-NMMA groups, respectively (all vs. placebo). Mean change in MAP at 2 h was -0.4, 4.4, 1.8, -4.1, and 6.8 mmHg in the placebo and four l-NMMA groups, respectively (all P = NS). Conclusion l-NMMA resulted in modest increases in MAP at 15 min compared with placebo but there were no differences at 2 h
— id: 71977, year: 2007, vol: 28, page: 1109, stat: Journal Article,

Cardiovascular outcomes in high-risk patients with osteoarthritis treated with Ibuprofen, Naproxen, or Lumiracoxib
Farkouh, M E; Greenberg, J D; Jeger, R V; Ramanathan, K; Verheugt, F W A; Chesebro, J H; Kirshner, H; Hochman, J S; Lay, C L; Ruland, S; Mellein, B; Matchaba, P T; Fuster, V; Abramson, S B
2007 Jun;66(6):764-770, Annals of rheumatic diseases
BACKGROUND: Evidence suggests that both selective cyclooxygenase (COX)-2 inhibitors and non-selective NSAIDs increase the risk of cardiovascular (CV) events. However, evidence from prospective studies of currently available COX-2 inhibitors and non-selective NSAIDs is lacking in high CV risk patients taking aspirin. METHODS: The Therapeutic Arthritis Research and Gastrointestinal Event Trial (TARGET) of 18,325 osteoarthritis patients comprised 2 parallel sub- studies, comparing lumiracoxib (COX-2 inhibitor) to either ibuprofen or naproxen. We performed a post hoc analysis stratified by baseline cardiovascular risk, treatment assignment, and low-dose aspirin use. The primary composite endpoint was cardiovascular mortality, nonfatal myocardial infarction, and stroke at 1 year; a secondary endpoint was the development of congestive heart failure (CHF). RESULTS: In high risk patients among aspirin users, patients in the ibuprofen sub-study had more primary events with ibuprofen than lumiracoxib (2.14% vs. 0.25%, p=0.038), whereas in the naproxen sub-study rates were similar for naproxen and lumiracoxib (1.58% vs. 1.48%, p=0.899). High risk patients not taking aspirin had fewer primary events with naproxen versus lumiracoxib (0% vs. 1.57%, p=0.027), but not ibuprofen versus lumiracoxib (0.92% vs. 0.80%, p=0.920). Overall, CHF developed more often with ibuprofen than lumiracoxib (1.28% vs. 0.14%; p=0.031), whereas no difference existed between naproxen and lumiracoxib. CONCLUSIONS: These data suggest that ibuprofen may confer an increased risk of thrombotic and CHF events relative to lumiracoxib among aspirin users at high cardiovascular risk. Our study indicates that naproxen may be associated with lower risk relative to lumiracoxib among non-aspirin users. Our data should be interpreted as hypothesis-generating
— id: 71979, year: 2007, vol: 66, page: 764, stat: Journal Article,

Persistent coronary occlusion after myocardial infarction
Hochman, JS; Forman, S; Reynolds, HR
2007 APR 19 ;356(16):1683-1684, New England journal of medicine
— id: 71613, year: 2007, vol: 356, page: 1683, stat: Journal Article,

The calm after the storm: long-term survival after cardiogenic shock
Hochman, Judith S; Apolito, Renato
2007 Oct 30;50(18):1759-1760, Journal of the American College of Cardiology
— id: 96641, year: 2007, vol: 50, page: 1759, stat: Journal Article,

Does preventive PCI work?
Hochman, Judith S; Steg, P Gabriel
2007 Apr 12;356(15):1572-1574, New England journal of medicine
— id: 71981, year: 2007, vol: 356, page: 1572, stat: Journal Article,

Causes of death and re-hospitalization in cardiogenic shock
Jeger, Raban V; Assmann, Susan F; Yehudai, Loran; Ramanathan, Krishnan; Farkouh, Michael E; Hochman, Judith S
2007 ;9(1):25-33, Acute Cardiac Care
Background: In cardiogenic shock, causes of death usually are cardiac. However, a systemic inflammatory response syndrome may influence outcome. Methods: SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? (SHOCK) Trial patients (n = 302) were analyzed regarding cause of death and re-hospitalization. Results: Deaths (n = 180) occurred </=30 days in 86% and >30 days in 14%. Known causes of death </=30 days were cardiac in 88% (37% arrhythmic) and non-cardiac in 12% (29% septic). Non-cardiac deaths </=30 days occurred later (206 [91,394] versus 41 [15,156] h, P<0.01) and were more frequently associated with signs of inflammation (43 versus 12%, P = 0.01) than cardiac deaths </=30 days. Known causes of in-hospital death >30 days (n = 19) were cardiac in 58% and non-cardiac in 42%. Among deaths </=30 days systemic vascular resistance index was higher (2,666+/-1,063 versus 2,090+/-731 dynes.sec.cm(-5) m(2), P = 0.05) than among deaths >30 days. Among the 116 survivors of the initial hospitalization with data available, 52 (45%) were readmitted, most of which due to heart failure (n = 22, 42%) and myocardial ischemia (n = 16, 31%). Conclusions: In CS, early deaths </=30 days are mainly cardiac. Non-cardiac deaths are associated with signs of inflammation. In survivors of the initial hospitalization, re-hospitalizations are due to heart failure and myocardial ischemia
— id: 71978, year: 2007, vol: 9, page: 25, stat: Journal Article,

Hemodynamic parameters are prognostically important in cardiogenic shock but similar following early revascularization or initial medical stabilization: a report from the SHOCK Trial
Jeger, Raban V; Lowe, April M; Buller, Christopher E; Pfisterer, Matthias E; Dzavik, Vladimir; Webb, John G; Hochman, Judith S; Jorde, Ulrich P
2007 Dec;132(6):1794-1803, Chest
BACKGROUND: In cardiogenic shock (CS), conclusive data on serial hemodynamic measurements for treatment guidance and prognosis are lacking. METHODS: The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock?) Trial tested early revascularization (ERV) vs initial medical stabilization (IMS) in CS complicating acute myocardial infarction and serially assessed hemodynamics by pulmonary artery catheter. RESULTS: Data were available in 278 patients (95%) surviving to the first measurement with predominant left ventricular failure at baseline and in 174 patients (70%) at follow-up. Baseline and follow-up hemodynamic data were similar in the treatment groups. The median time from CS to baseline measurements was 3.3 h in both treatment groups, whereas follow-up measurements were obtained earlier in the IMS group (median time, 10.6 h) than in the ERV group (median time, 12.5 h; p = 0.043). At baseline, stroke volume index (SVI) was an independent predictor of 30-day mortality after adjustment for age (odds ratio, 0.69 per 5 mL/m2 increase; 95% confidence interval, 0.55 to 0.87; p = 0.002). At follow-up, both stroke work index (SWI) [odds ratio, 0.54 per 5 g/m/m2 increase; 95% confidence interval, 0.39 to 0.76; p < 0.001] and SVI (odds ratio, 0.59 per 5 mL/m2 increase; 95% confidence interval, 0.45 to 0.77; p < 0.001) were similarly powerful predictors of 30-day mortality after adjustment for age. CONCLUSIONS: SVI and SWI are the most powerful hemodynamic predictors of 30-day mortality in CS patients. Hemodynamic parameters are similar for surviving patients following ERV and IMS. Thus, early hemodynamic stability after IMS should not delay revascularization since long-term outcomes are superior with ERV
— id: 76080, year: 2007, vol: 132, page: 1794, stat: Journal Article,

Microbiological profile of septic complication in patients with cardiogenic shock following acute myocardial infarction (from the SHOCK study)
Kohsaka, Shun; Menon, Venu; Iwata, Kentaro; Lowe, April; Sleeper, Lynn A; Hochman, Judith S
2007 Mar 15;99(6):802-804, American journal of cardiology
We sought to assess the microbiologic profile of patients with suspected sepsis who participated in the SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? (SHOCK) trial, a randomized controlled trial of early coronary revascularization in patients with cardiogenic shock complicating acute myocardial infarction. A protocol-mandated SEPSIS form was completed prospectively for 54 patients (18%) with fever or leukocytosis suggestive of sepsis. These patients were divided further into those with positive (n = 40) or negative (n = 14) culture results. The predominant pathogen isolated in patients with positive culture results was Staphylococcus aureus (32%), followed by Klebsiella pneumoniae and Pseudomonas aeruginosa. Patients with both positive and negative culture results had longer median durations of mechanical ventilation (p <0.001 and p = 0.02), intra-aortic balloon pump (IABP) support (p = 0.074 and p = 0.021), and hospital stay (p <0.001 and p = 0.048) than controls. Sepsis was predicted by both duration of IABP support (p = 0.007) and use of multiple central catheters (p = 0.026). In conclusion, clinical sepsis is common after cardiogenic shock complicating acute myocardial infarction, particularly in patients who received prolonged IABP support or had multiple central catheters
— id: 71982, year: 2007, vol: 99, page: 802, stat: Journal Article,

Predictors of outcome and the lack of effect of PCI across the risk strata in patients with persistent total occlusion after myocardial infarction: Results from the occluded artery trial (OAT)
Kruk, M; Kadziela, J; Sadowski, ZP; Barton, BA; Mark, DB; Forman, SA; Reynolds, HR; Maggioni, AP; Leor, J; Webb, JG; Kapeliovich, M; Marin-Neto, JA; Preto, R; White, HD; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):625-625, Circulation
— id: 75977, year: 2007, vol: 116, page: 625, stat: Journal Article,

Where does the Occluded Artery Trial leave the late open artery hypothesis?
Lamas, Gervasio A; Hochman, Judith S
2007 Nov;93(11):1319-1321, Heart (British Cardiac Society)
As of April 2007 the early open artery hypothesis is alive and well, but the late open artery hypothesis is adrift. For the foreseeable future, stable patients with persistent occlusion of the infarct artery late after myocardial infarction, and without severe ischaemia or uncontrollable angina, should be managed initially with optimal medical treatment alone, and not with percutaneous coronary intervention. Efforts should focus on establishing reperfusion earlier, including reducing the time to patient presentation
— id: 96642, year: 2007, vol: 93, page: 1319, stat: Journal Article,

Causes of death in early MI survivors with persistent vessel occlusion: Results from the occluded artery trial (OAT)
Lang, I; Forman, SA; Maggiohi, AP; Ruzyllo, W; Vozzi, C; Renkin, J; Steg, PG; Hemandez-Gardia, JM; Zmudka, K; Jimenez-Navarro, M; Sopko, G; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):625-625, Circulation
— id: 75979, year: 2007, vol: 116, page: 625, stat: Journal Article,

Outcome following coronary artery bypass grafting and percutaneous coronary intervention for acute myocardial infarction complicated by Cardiogenic shock and left main coronary artery stenosis: A report from the SHOCK trial and registry
Lee, MS; Barker, CM; Menon, V; Steckman, D; Tseng, CH; Hochman, JS
2007 OCT 16 ;116(16):394-394, Circulation
— id: 75969, year: 2007, vol: 116, page: 394, stat: Journal Article,

PCI in the OAT trial: Lots of bucks, not much bang
Mark, DB; Pan, WQ; Clapp-Channing, NE; Davidson-Ray, L; Ross, J; Fox, R; Devlin, G; Martin, E; Cohen, EA; Lamas, GA; Hochman, JS
2007 NOV 27 ;116(22):2630-2630, Circulation
— id: 75215, year: 2007, vol: 116, page: 2630, stat: Journal Article,

Anti-ischemic effects of ranolazine in women: Results from the randomized, placebo-controlled MERLIN-TIMI 36 trial
Mega, JL; Hochman, JS; Scirica, BM; Murphy, SA; McCabe, CH; Merlini, P; Morrow, DA
2007 OCT 16 ;116(16):539-539, Circulation
— id: 75975, year: 2007, vol: 116, page: 539, stat: Journal Article,

Metabolic profiling of arginine and nitric oxide pathways predicts hemodynamic abnormalities and mortality in patients with cardiogenic shock after acute myocardial infarction
Nicholls, Stephen J; Wang, Zeneng; Koeth, Robert; Levison, Bruce; DelFraino, Brian; Dzavik, Vladimir; Griffith, Owen W; Hathaway, David; Panza, Julio A; Nissen, Steven E; Hochman, Judith S; Hazen, Stanley L
2007 Nov 13;116(20):2315-2324, Circulation
BACKGROUND: It is unclear whether abnormalities of arginine and nitric oxide metabolism are related to hemodynamic dysfunction and mortality in patients with cardiogenic shock (CS) after acute myocardial infarction. METHODS AND RESULTS: Plasma metabolites reflecting arginine bioavailability, nitric oxide metabolism, and protein oxidation were analyzed by mass spectrometry in patients with CS (n=79) and age- and gender-matched patients with coronary artery disease and normal left ventricular function (n=79). CS patients had higher levels of asymmetric dimethylarginine (ADMA; P<0.0001), symmetric dimethylarginine (P<0.0001), monomethylarginine (P=0.0003), nitrotyrosine (P<0.0001), and bromotyrosine (P<0.0001) and lower levels of arginine (P<0.0001), ratio of arginine to ornithine (P=0.03), and ratio of arginine to ornithine plus citrulline) (P=0.0003). CS patients with elevated ADMA levels were 3.5-fold (95% confidence interval, 1.4 to 11.3; P=0.02) more likely to die in 30 days than patients with low ADMA levels. ADMA remained the only independent predictor of mortality on multiple logistic regression analysis. In patients with normal renal function, symmetric dimethylarginine levels inversely correlated with mean arterial pressure and systemic vascular resistance, whereas levels of ADMA correlated with pulmonary capillary wedge pressure and both systolic and diastolic pulmonary artery pressures. Despite dramatic elevations, levels of protein oxidation products did not predict hemodynamic dysfunction or mortality in CS patients. CONCLUSIONS: CS is characterized by an arginine-deficient and highly specific pro-oxidant state, with elevated levels of methylated arginine derivatives, including endogenous nitric oxide synthase inhibitors. Levels of methylated arginine derivatives strongly correlate with hemodynamic dysfunction. Among all clinical and laboratory parameters monitored, ADMA levels were the strongest independent predictor of 30-day mortality
— id: 96640, year: 2007, vol: 116, page: 2315, stat: Journal Article,

Impact of female sex on death and bleeding after fibrinolytic treatment of myocardial infarction in GUSTO V
Reynolds, Harmony R; Farkouh, Michael E; Lincoff, A Michael; Hsu, Amy; Swahn, Eva; Sadowski, Zygmunt P; White, Jennifer A; Topol, Eric J; Hochman, Judith S
2007 Oct 22;167(19):2054-2060, Archives of internal medicine
BACKGROUND: Women with acute myocardial infarction are more likely than men to experience reinfarction, bleeding, or death. This difference has been hypothesized to be due to older age, treatment delay, and comorbidities in women. Use of diagnostic and therapeutic modalities may also differ. There is controversy regarding whether female sex is an independent risk factor for death and/or bleeding. METHODS: The GUSTO (Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes) V Investigators studied standard-dose reteplase vs standard-dose abciximab plus half-dose reteplase in patients with myocardial infarction. RESULTS: Women were older and more often had diabetes mellitus and hypertension. Angiography and percutaneous coronary intervention were less frequent in women. Death (9.8% vs 4.4% at 30 days; odds ratio [OR], 2.00; 95% confidence interval, 1.59-2.53; P < .001) and bleeding (6.4% vs 2.5%; OR, 1.31; 95% confidence interval, 1.18-1.45; P < .01) were more common in women. There was no association between treatment assignment and death in either sex; bleeding was more common in both sexes receiving combination therapy. Female sex was independently associated with mortality. After Killip class greater than 1 (OR, 4.7), female sex (OR, 2.0) was the strongest correlate of death. Female sex was independently associated with bleeding for both treatments. CONCLUSIONS: Female sex is independently associated with death and bleeding complications among fibrinolytic-treated patients with myocardial infarction. There remains a sex differential in the use of angiography and, therefore, percutaneous coronary intervention after fibrinolysis. Further research will determine what mediates excess risk in women
— id: 75395, year: 2007, vol: 167, page: 2054, stat: Journal Article,

The occluded artery trial (OAT) viability ancillary study (OAT-NUC): Influence of infarct zone viability on left ventricular remodeling after PCI vs. medical therapy alone
Udelson, JE; Pearte, CA; Kimmelstiel, CD; Kruk, M; Teresinska, A; Bychowiec, B; Marin-Neto, JA; Preto, R; Hochtl, T; Cohen, EA; Caramori, P; Busz-Papiez, B; AdIbrecht, C; Sadowski, ZP; Ruzyllo, W; Forman, SA; Kinan, DJ; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):624-625, Circulation
— id: 75976, year: 2007, vol: 116, page: 624, stat: Journal Article,

Predictors of reinfarction following PCI or medical management in patients with persistent total occlusion after myocardial infarction: Results from the occluded artery trial (OAT)
White, HD; Steg, PG; Dzavik, V; Menon, V; Reynolds, HR; Carvalho, AC; Barton, BA; Cantor, WJ; Kruk, M; Martin, CE; Pearle, CA; Knatterud, GL; Lamas, GA; Hochman, JS
2007 OCT 16 ;116(16):625-625, Circulation
— id: 75978, year: 2007, vol: 116, page: 625, stat: Journal Article,

Use of evidence-based medicine for acute coronary syndromes in the elderly and very elderly: insights from the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes trials
Wong, Cheuk-Kit; Newby, L Kristin; Bhapker, Manju V; Aylward, Phil E; Pfisterer, Matthias; Alexander, Karen P; Armstrong, Paul W; Hochman, Judith S; Van de Werf, Frans; Califf, Robert M; White, Harvey D
2007 Aug;154(2):313-321, American heart journal
BACKGROUND: Evidence-based medications (EBM) are underused in older patients despite potentially larger absolute benefits. Little is known about factors influencing prescribing in the elderly with acute coronary syndromes. METHODS: Among the 15,904 patients from the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes (SYMPHONY) and second SYMPHONY trials, we examined the rates of use of EBM according to age (< 75 or > or = 75 years, and 3 subgroups of 5 year increments among patients > or = 75 years). RESULTS: Ninety-day mortality increased with age (< 75 years, 1.3%; > or = 75 to < 80 years, 4.4%; > or = 80 to < 85 years, 6.0%; > or = 85 years, 9.6%). Compared with subjects < 75 years (n = 14,043), acute EBM use was lower among patients > or = 75 years (n = 1794): aspirin (83% vs 85%), heparin (73% vs 78%), and beta-blockers (70% vs 76%). Similarly, discharge use of beta-blockers (69% vs 76%) and statins (28% vs 40%) was lower, although this was not the case for angiotensin-converting enzyme inhibitors (44% vs 41%). These patterns persisted among eligible patients. Beyond the age of 75 years, EBM use was not further influenced by age except for statins and angiotensin-converting enzyme inhibitors, which were used less frequently in those > or = 85 years. Among patients aged > or = 75 years, prediction for use of each EBM in multivariable modeling was modest (C indices, approximately 0.7); except for statins, increasing age did not predict lower EBM use. CONCLUSIONS: Despite higher mortality risk, EBM use was lower among older patients even considering eligibility. Among those aged > or = 75 years, age was no longer the major factor predicting EBM use. The modest C indices suggest other factors are associated with prescribing, underscoring the need for treatment algorithms and quality assurance measures in older patients
— id: 101574, year: 2007, vol: 154, page: 313, stat: Journal Article,

Sex differences in major bleeding with glycoprotein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) initiative
Alexander, Karen P; Chen, Anita Y; Newby, L Kristin; Schwartz, Janice B; Redberg, Rita F; Hochman, Judith S; Roe, Matthew T; Gibler, W Brian; Ohman, E Magnus; Peterson, Eric D
2006 Sep 26;114(13):1380-1387, Circulation
BACKGROUND: Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS); their safe use in women, however, remains a concern. The contribution of dosing to the observed sex-related differences in bleeding is unknown. METHODS AND RESULTS: We explored the relationship between patient sex, GP IIb/IIIa inhibitor use, dose, and bleeding in 32 601 patients with NSTE ACS across 400 CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) hospitals, of whom 18 436 were treated. GP IIb/IIIa inhibitor dose was defined as excessive if not reduced when creatinine clearance was < 50 mL/min for eptifibatide or < 30 mL/min for tirofiban. Major bleeding was defined as a hematocrit drop > or = 0.12, need for transfusion, or intracranial bleeding. Major bleeding was adjusted for clinical factors and antithrombotic dose. The risk for bleeding attributable to excess GP IIb/IIIa dose was determined by sex using prevalence and adjusted odds ratios (ORs). Women had higher rates of major bleeding than men among those treated with GP IIb/IIIa inhibitors (15.7% versus 7.3%, P<0.0001) and among those not treated (8.5% versus 5.4%, P<0.0001). Despite similar serum creatinine levels, creatinine clearance averaged 20 points lower among treated women than men. Treated women were also more likely to receive excess GP IIb/IIIa doses than men (46.4% versus 17.2%, P<0.0001; adjusted OR 3.81, 95% confidence interval [CI] 3.39 to 4.27). Excess dosing was associated with increased risk of bleeding in women (OR 1.72, 95% CI 1.30 to 2.28) and men (OR 1.27, 95% CI 0.97 to 1.66); however, bleeding risk attributable to dosing was much higher in women (25.0% versus 4.4%). CONCLUSIONS: Women experience more bleeding than men whether or not they are treated with GP IIb/IIIa inhibitors; however, because of frequent excessive dosing in women, up to one fourth of this sex-related risk difference in bleeding is avoidable. Appropriate dosing will improve care of all patients with NSTE ACS, with a particular benefit for women
— id: 71986, year: 2006, vol: 114, page: 1380, stat: Journal Article,

International variation in invasive care of the elderly with acute coronary syndromes
Alexander, Karen P; Newby, Laura Kristin; Bhapkar, Manju V; White, Harvey D; Hochman, Judith S; Pfisterer, Matthias E; Moliterno, David J; Peterson, Eric D; Van de Werf, Frans; Armstrong, Paul W; Califf, Robert M
2006 Jul;27(13):1558-1564, European heart journal
AIMS: To explore variations in invasive care of the elderly with acute coronary syndromes across international practice. METHODS AND RESULTS: Using combined populations from the SYMPHONY and 2nd SYMPHONY trials, we describe 30-day cardiac catheterization in elderly (> or = 75 years; n = 1794) vs. younger patients (< 75 years; n = 14,043) after multivariable adjustment and by region of enrolment. The use of cardiac catheterization and revascularization were not protocol-specified. Elderly patients (median age 78 years) were more often female and more frequently had hypertension, diabetes, prior myocardial infarction, and prior coronary bypass surgery. Overall, they underwent less cardiac catheterization than younger patients [53 vs. 63%; adjusted OR 0.53 (0.46, 0.60)]. The absolute rate of cardiac catheterization in the elderly varied from 77% (vs. 91% in younger patients) in the US cohort to 27% (vs. 41% in younger patients) in the non-US cohort. Revascularization of elderly who underwent cardiac catheterization was also higher in US than non-US cohorts (71.3 vs. 53.6%). There was a significant interaction between the patient age and the use of catheterization across US and non-US regions of enrolment, as well as differences in the predictors of catheterization in the elderly. Despite these findings, after adjustment, 90-day rates of death and death or myocardial infarction (MI) were not significantly different in elderly who underwent catheterization compared with those who did not. CONCLUSION: Although older age is universally predictive of lower use of cardiac catheterization, marked variation in catheterization of the elderly exists across international practice. Demonstrated differences in patterns of use suggest a lack of consensus regarding optimal use of an invasive strategy in the elderly
— id: 71988, year: 2006, vol: 27, page: 1558, stat: Journal Article,

Concerning the mechanism of pexelizumab's benefit in acute myocardial infarction
Armstrong, Paul W; Mahaffey, Kenneth W; Chang, Wei-Ching; Weaver, W Douglas; Hochman, Judith S; Theroux, Pierre; Rollins, Scott; Todaro, Thomas G; Granger, Christopher B
2006 Apr;151(4):787-790, American heart journal
BACKGROUND: The COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA) trial previously demonstrated an unexpected dose-dependent reduction in 90-day mortality after bolus/infusion of pexelizumab despite no reduction in the primary end point of myocardial infarction (MI) size. We examined whether the mortality benefit was related to established modulators of clinical benefit such as baseline demographics, time to treatment from symptom onset, myocardial perfusion post-percutaneous coronary intervention (PCI), and extent of ST resolution. METHODS AND RESULTS: Eight hundred fourteen patients were randomized into 3 groups; (1) placebo, (2) pexelizumab bolus 2.0 mg/kg and placebo infusion for 20 hours, and (3) pexelizumab bolus 2.0 and 0.05 mg/kg per hour infusion for 20 hours commencing 4 hours after the bolus. Subjects presented with ST elevation MI within 6 hours of symptom onset and underwent PCI, creatine kinase (CK), and CK-MB measurements taken sequentially to define CK-MB area under the curve (AUC) and sequential ECG's defined ST resolution and QRS infarct size. Whereas mortality for both placebo and bolus pexelizumab groups rose during later time after presentation, it remained low and did not change appreciably during the 6-hour randomization window when patients received pexelizumab bolus infusion. Amplification of the mortality benefit was evident in patients with the highest quartile of hemodynamic compromise, that is, heart rate > or = 90 beat/min and systolic blood pressure < or = 118 mm Hg (3.2% vs 11.3% P = .004). A significant interaction between treatment assignment and hemodynamic status (P = .013) existed after adjusting for age, race, and MI location. Clinical benefit was not related to infarct size, extent of ST elevation, or evidence of angiographic or electrocardiographic reperfusion. CONCLUSIONS: These data raise the possibility that the clinical benefit of pexelizumab is mediated through novel pathways such as reduction in apoptosis or other mechanisms
— id: 71992, year: 2006, vol: 151, page: 787, stat: Journal Article,

Echocardiographic and angiographic correlations in patients with cardiogenic shock secondary to acute myocardial infarction
Berkowitz, M Joshua; Picard, Michael H; Harkness, Shannon; Sanborn, Timothy A; Hochman, Judith S; Slater, James N
2006 Oct 15;98(8):1004-1008, American journal of cardiology
In patients with cardiogenic shock (CS) complicating acute myocardial infarction, echocardiographic and angiographic findings are used to aid diagnosis, determine prognosis, and guide management. The purpose of this analysis from the Should we emergently revascularize Occluded Coronary arteries for Cardiogenic ShocK (SHOCK) trial is to identify relations between the angiographic and echocardiographic features of patients with CS. Such an analysis of the correlations between echocardiographic and angiographic findings in patients with CS may provide insights into the etiology and treatment of CS. In 302 randomized patients, an echocardiogram and an angiogram before revascularization were available in 127 patients. Although the median ejection fraction derived by echocardiography and left ventricular angiography was identical (30%), the positive correlation was weak (R2 = 0.209, p = 0.019). Patients with a larger number of diseased vessels had worse mitral regurgitation (MR) by echocardiography (p = 0.005). There was a significant but weak association between left ventricular angiographic MR grade and echocardiographic MR severity (R2 = 0.162, p = 0.015), but there was no association between culprit vessel and degree of MR. In conclusion, worse coronary artery disease is associated with more severe MR. Echocardiography and angiography are valuable and result in similar estimated ejection fractions in a large cohort, but there is wide variation between the techniques in patients
— id: 71985, year: 2006, vol: 98, page: 1004, stat: Journal Article,

Frequency and consequences of recording an electrocardiogram >10 minutes after arrival in an emergency room in non-ST-segment elevation acute coronary syndromes (from the CRUSADE Initiative)
Diercks, Deborah B; Peacock, W Frank; Hiestand, Brian C; Chen, Anita Y; Pollack, Charles V Jr; Kirk, J Douglas; Smith, Sidney C Jr; Gibler, W Brian; Ohman, E Magnus; Blomkalns, Andra L; Newby, L Kristin; Hochman, Judith S; Peterson, Eric D; Roe, Matthew T
2006 Feb 15;97(4):437-442, American journal of cardiology
We sought to determine the frequency of electrocardiographic (ECG) acquisition within 10 minutes of hospital arrival, factors associated with delayed ECG acquisition, and any relation among delayed ECG acquisition, treatment patterns, and clinical outcomes. We therefore analyzed data from 63,478 patients (26,615 women, 42%) with high-risk non-ST-segment elevation acute coronary syndromes (designated by positive cardiac markers and/or ischemic ST-segment changes) who were enrolled in the CRUSADE Quality Improvement Initiative from February 2001 to March 2004. Patients were categorized based on time to electrocardiography as delayed (>10 minutes from hospital arrival) or nondelayed (<10 minutes). Multivariable predictors of delayed ECG acquisition were determined. Overall, median time to electrocardiography was 15 minutes (25th to 75th percentile 7 to 32). ECG acquisition was delayed (median 25 minutes, 25th to 75th percentile 16 to 50) in 41,397 patients (65.2%). In the remaining 34.8%, time to electrocardiography was <10 minutes (median 5 minutes, 25th to 75th percentile 3 to 8). Women were more likely than men to have delayed ECG acquisition (69% vs 62%), and female gender was the most significant predictor of delayed ECG acquisition (odds ratio 1.29, 95% confidence interval 1.25 to 1.34). In conclusion, only 33% of high-risk patients with non-ST-segment elevation acute coronary syndrome had an initial electrocardiogram obtained <10 minutes of arrival as recommended. Women were significantly more likely than men to have delayed ECG acquisition. Emergency departments should focus on decreasing the time to initial ECG acquisition to improve treatment of acute coronary syndrome in this group
— id: 71993, year: 2006, vol: 97, page: 437, stat: Journal Article,

Randomized trial of percutaneous coronary intervention for subacute infarct-related coronary artery occlusion to achieve long-term patency and improve ventricular function: the Total Occlusion Study of Canada (TOSCA)-2 trial
Dzavik, Vladimir; Buller, Christopher E; Lamas, Gervasio A; Rankin, James M; Mancini, G B John; Cantor, Warren J; Carere, Ronald J; Ross, John R; Atchison, Deborah; Forman, Sandra; Thomas, Boban; Buszman, Pawel; Vozzi, Carlos; Glanz, Anthony; Cohen, Eric A; Meciar, Peter; Devlin, Gerald; Mascette, Alice; Sopko, George; Knatterud, Genell L; Hochman, Judith S
2006 Dec 5;114(23):2449-2457, Circulation
BACKGROUND: In the present study, we sought to determine whether opening a persistently occluded infarct-related artery (IRA) by percutaneous coronary intervention (PCI) in patients beyond the acute phase of myocardial infarction (MI) improves patency and indices of left ventricular (LV) size and function. METHODS AND RESULTS: Between May 2000 and July 2005, 381 patients with an occluded native IRA 3 to 28 days after MI (median 10 days) were randomized to PCI with stenting (PCI) or optimal medical therapy alone. Repeat coronary and LV angiography was performed 1 year after randomization (n=332, 87%). Coprimary end points were IRA patency and change in LV ejection fraction. Secondary end points included change in LV end-systolic and end-diastolic volume indices and wall motion. PCI was successful in 92%. At 1 year, 83% of PCI versus 25% of medical therapy-only patients had a patent IRA (P<0.001). LV ejection fraction increased significantly (P<0.001) in both groups, with no between-group difference: PCI 4.2+/-8.9 (n=150) versus medical therapy 3.5+/-8.2 (n=136; P=0.47). Median change (interquartile range) in LV end-systolic volume index was -0.5 (-9.3 to 5.0) versus 1.0 (-5.7 to 7.3) mL/m2 (P=0.10), whereas median change (interquartile range) in LV end-diastolic volume index was 3.2 (-8.2 to 13.3) versus 5.3 (-4.6 to 23.2) mL/m2 (P=0.07) in the PCI (n=86) and medical therapy-only (n=76) groups, respectively. CONCLUSIONS: PCI with stenting of a persistently occluded IRA in the subacute phase after MI effectively maintains long-term patency but has no effect on LV ejection fraction. On the basis of these findings and the lack of clinical benefit in the main Occluded Artery Trial, routine PCI is not recommended for stable patients with a persistently occluded IRA after MI
— id: 71983, year: 2006, vol: 114, page: 2449, stat: Journal Article,

N-terminal pro-brain natriuretic peptide and the timing, extent and mortality in ST elevation myocardial infarction
Ezekowitz, Justin A; Theroux, Pierre; Chang, Weiching; Mahaffey, Kenneth W; Granger, Christopher B; Weaver, W D; Hochman, Judith S; Armstrong, Paul W
2006 Apr;22(5):393-397, Canadian journal of cardiology
AIMS: While natriuretic peptides have demonstrated diagnostic and prognostic potential in cardiac disorders, little is known about their relationship with the onset and quantification of myocardial infarction. The relationship of serial N-terminal pro-brain natriuretic peptide (NT-proBNP) with duration from symptom onset, infarct size and prognosis in ST elevation myocardial infarction (STEMI) patients treated with primary percutaneous intervention was examined. METHODS AND RESULTS: Three hundred thirty-one STEMI patients in the COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA) trial, which evaluated pexelizumab versus placebo, were studied. NT-proBNP (pg/mL) was measured at randomization, 24 h and 72 h; creatine kinase-MB area under the curve was measured at 72 h; and QRS score was assessed at discharge. Prognosis was ascertained from the 90-day composite clinical outcome of death, shock, stroke and congestive heart failure. Multivariate logistical regression was used to adjust for baseline characteristics for models at randomization, 24 h and 72 h. NT-proBNP was higher in patients with longer time from symptom onset (P<0.001) and correlated with measures of infarct size, including the area under the curve (P<0.001) and QRS score (P<0.001). Patients reaching the primary end point had markedly higher NT-proBNP at each sampling period (P<0.001). NT-proBNP at all time points was the strongest independent predictor of the primary end point in the multivariate model: in the 24 h model, only age and 24 h NT-proBNP (C-index 0.83); and only age, Killip class and NT-proBNP was in the 72 h model (C-index 0.85). CONCLUSIONS: Higher NT-proBNP at 24 h correlated with larger infarct size and worse clinical outcomes. NT-proBNP at baseline, 24 h and 72 h after presentation with acute STEMI, is an independent predictor of a poor outcome and adds clinically useful prognostic information
— id: 71990, year: 2006, vol: 22, page: 393, stat: Journal Article,

An early revascularization strategy is associated with a survival benefit for diabetic patients in cardiogenic shock after acute myocardial infarction
Farkouh, Michael E; Ramanathan, Krishnan; Aymong, Eve D; Webb, John G; Harkness, Shannon M; Sleeper, Lynn A; Hochman, Judith S
2006 May;29(5):204-210, Clinical cardiology
BACKGROUND: The role of diabetes mellitus (DM) in cardiogenic shock (CS) complicating an acute myocardial infarction (AMI) is not well understood. Previous studies have reported an in-hospital mortality rate for patients with DM and CS of about 60%. OBJECTIVES: This study compares the 1-year mortality rates of patients with DM and those without (NDM) and evaluates early revascularization (ERV) compared with initial medical stabilization (IMS) in patients with DM and CS. Methods: Baseline characteristics, clinical and hemodynamic measures, and management were compared for 90 patients (31%) with DM and 198 with NDM (69%) who were randomized to ERV or IMS in the SHOCK Trial. RESULTS: When compared with NDM, patients with DM were of similar age but had higher rates of prior MI (44.4 vs. 27.8%, p = 0.007) and hypertension (56.2 vs. 42.5%, p = 0.04). The DM group had a lower rate of fibrinolytic therapy (44.4 vs. 60.1%, p = 0.02). In patients randomized to ERV, patients with DM had a higher rate of coronary artery bypass grafting (CABG) (50.0 vs. 30.9%, p = 0.03) despite similar rates of triple-vessel disease. The 1-year mortality rates in both groups were equivalent (58.9%). One-year mortality was not associated with diabetes (hazard ratio [HR] 1.02, 95% CI, 0.73-1.42, p = 0.91). The benefit of an ERV strategy was similar (HR [DM] 0.62; HR [NDM] 0.75, p = 0.58). Even after adjusting for the imbalance in CABG rates, 1-year mortality was not associated with DM. CONCLUSION: Diabetes mellitus is not a predictor of 1-year mortality in CS after AMI. The benefit from an ERV strategy is similar for DM and NDM. The management strategies and influence of DM on mortality in CS deserve further evaluation
— id: 71989, year: 2006, vol: 29, page: 204, stat: Journal Article,

Sex-related differences in non-obstructive coronary artery disease among patients with non-ST-segment elevation acute coronary syndromes: Results from the CRUSADE quality improvement initiative
Gehrie, ER; Reynolds, HR; Neelon, BH; Roe, MT; Gibler, WB; Ohman, EM; Newby, LK; Peterson, ED; Hochman, JS
2006 FEB 21 ;47(4):172A-172A, Journal of the American College of Cardiology
— id: 63304, year: 2006, vol: 47, page: 172A, stat: Journal Article,

Prognostic significance of the change in glucose level in the first 24 h after acute myocardial infarction: results from the CARDINAL study
Goyal, Abhinav; Mahaffey, Kenneth W; Garg, Jyotsna; Nicolau, Jose C; Hochman, Judith S; Weaver, W Douglas; Theroux, Pierre; Oliveira, Gustavo B F; Todaro, Thomas G; Mojcik, Christopher F; Armstrong, Paul W; Granger, Christopher B
2006 Jun;27(11):1289-1297, European heart journal
AIMS: In acute myocardial infarction (AMI), baseline hyperglycaemia predicts adverse outcomes, but the relation between subsequent change in glucose levels and outcomes is unclear. We evaluated the prognostic significance of baseline glucose and the change in glucose in the first 24 h following AMI. METHODS AND RESULTS: We analysed 1469 AMI patients with baseline and 24 h glucose data from the CARDINAL trial database. Baseline glucose and the 24 h change in glucose (24 h glucose level subtracted from baseline glucose) were included in multivariable models for 30- and 180-day mortality. By 30 and 180 days, respectively, 45 and 74 patients had died. In the multivariable 30-day mortality model, neither baseline glucose nor the 24 h change in glucose predicted mortality in diabetic patients (n=250). However, in nondiabetic patients (n=1219), higher baseline glucose predicted higher mortality [hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04-1.20, per 0.6 mmol/L increase], and a greater 24 h change in glucose predicted lower mortality (HR 0.91, 95% CI 0.86-0.96, for every 0.6 mmol/L drop in glucose in the first 24 h) at 30 days. Baseline glucose and the 24 h change in glucose remained significant multivariable mortality predictors at 180 days in nondiabetic patients. CONCLUSION: Both higher baseline glucose and the failure of glucose levels to decrease in the first 24 h after AMI predict higher mortality in nondiabetic patients
— id: 71991, year: 2006, vol: 27, page: 1289, stat: Journal Article,

The occluded artery trial (OAT)
Hochman, JS
2006 NOV 28 ;114(22):2425-2425, Circulation
— id: 70169, year: 2006, vol: 114, page: 2425, stat: Journal Article,

Coronary intervention for persistent occlusion after myocardial infarction
Hochman, Judith S; Lamas, Gervasio A; Buller, Christopher E; Dzavik, Vladimir; Reynolds, Harmony R; Abramsky, Staci J; Forman, Sandra; Ruzyllo, Witold; Maggioni, Aldo P; White, Harvey; Sadowski, Zygmunt; Carvalho, Antonio C; Rankin, Jamie M; Renkin, Jean P; Steg, P Gabriel; Mascette, Alice M; Sopko, George; Pfisterer, Matthias E; Leor, Jonathan; Fridrich, Viliam; Mark, Daniel B; Knatterud, Genell L
2006 Dec 7;355(23):2395-2407, New England journal of medicine
BACKGROUND: It is unclear whether stable, high-risk patients with persistent total occlusion of the infarct-related coronary artery identified after the currently accepted period for myocardial salvage has passed should undergo percutaneous coronary intervention (PCI) in addition to receiving optimal medical therapy to reduce the risk of subsequent events. METHODS: We conducted a randomized study involving 2166 stable patients who had total occlusion of the infarct-related artery 3 to 28 days after myocardial infarction and who met a high-risk criterion (an ejection fraction of <50% or proximal occlusion). Of these patients, 1082 were assigned to routine PCI and stenting with optimal medical therapy, and 1084 were assigned to optimal medical therapy alone. The primary end point was a composite of death, myocardial reinfarction, or New York Heart Association (NYHA) class IV heart failure. RESULTS: The 4-year cumulative primary event rate was 17.2% in the PCI group and 15.6% in the medical therapy group (hazard ratio for death, reinfarction, or heart failure in the PCI group as compared with the medical therapy group, 1.16; 95% confidence interval [CI], 0.92 to 1.45; P=0.20). Rates of myocardial reinfarction (fatal and nonfatal) were 7.0% and 5.3% in the two groups, respectively (hazard ratio, 1.36; 95% CI, 0.92 to 2.00; P=0.13). Rates of nonfatal reinfarction were 6.9% and 5.0%, respectively (hazard ratio, 1.44; 95% CI, 0.96 to 2.16; P=0.08); only six reinfarctions (0.6%) were related to assigned PCI procedures. Rates of NYHA class IV heart failure (4.4% vs. 4.5%) and death (9.1% vs. 9.4%) were similar. There was no interaction between treatment effect and any subgroup variable (age, sex, race or ethnic group, infarct-related artery, ejection fraction, diabetes, Killip class, and the time from myocardial infarction to randomization). CONCLUSIONS: PCI did not reduce the occurrence of death, reinfarction, or heart failure, and there was a trend toward excess reinfarction during 4 years of follow-up in stable patients with occlusion of the infarct-related artery 3 to 28 days after myocardial infarction. (ClinicalTrials.gov number, NCT00004562 [ClinicalTrials.gov].)
— id: 69605, year: 2006, vol: 355, page: 2395, stat: Journal Article,

What price pain relief?
Hochman, Judith S; Shah, Nirav R
2006 Jun 27;113(25):2868-2870, Circulation
— id: 71987, year: 2006, vol: 113, page: 2868, stat: Journal Article,

Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction
Hochman, Judith S; Sleeper, Lynn A; Webb, John G; Dzavik, Vladimir; Buller, Christopher E; Aylward, Philip; Col, Jacques; White, Harvey D
2006 Jun 7;295(21):2511-2515, JAMA
CONTEXT: Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction (MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking. OBJECTIVE: To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI. DESIGN, SETTING, AND PATIENTS: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock (mean [SD] age at randomization, 66 [11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years (median for survivors, 6 years). MAIN OUTCOME MEASURES: All-cause mortality during long-term follow-up. RESULTS: The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years (13.1% and 13.2%, respectively; hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.57-0.97; log-rank P = .03). At 6 years, overall survival rates were 32.8% and 19.6% in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed (HR, 0.59; 95% CI, 0.36-0.95; P = .03). The 6-year survival rates for the hospital survivors were 62.4% vs 44.4% for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3% vs 14.3% and, for the 1-year survivors, 8.0% vs 10.7%. There was no significant interaction between any subgroup and treatment effect. CONCLUSIONS: In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2% absolute and a 67% relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00000552
— id: 64483, year: 2006, vol: 295, page: 2511, stat: Journal Article,

Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry
Jeger, Raban V; Harkness, Shannon M; Ramanathan, Krishnan; Buller, Christopher E; Pfisterer, Matthias E; Sleeper, Lynn A; Hochman, Judith S
2006 Mar;27(6):664-670, European heart journal
AIMS: To determine clinical correlates and optimal treatment strategy in patients with cardiogenic shock (CS) on admission. METHODS AND RESULTS: In SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? (SHOCK) trial and registry patients with left ventricular (LV) dysfunction (n=1053), CS on admission occurred in 26% of directly admitted patients (n=166/627). Time from myocardial infarction to CS was shorter, initial haemodynamic profile poorer, and aggressive treatment less frequent in CS on admission than in delayed CS patients. CS on admission patients constituted a smaller relative proportion (11%) of the transferred (n=48/426) when compared with the directly admitted cohort (P<0.001). In-hospital mortality was higher (75 vs. 56%; P<0.001) with more rapid death (24-h mortality 40 vs. 17%; P<0.001) in CS on admission than in delayed CS patients. Emergency revascularization reduced in-hospital mortality in CS on admission (60 vs. 82%; P=0.001) and in delayed CS patients similarly (46 vs. 62%; P<0.001; interaction P=0.25). After adjustment for clinical differences, CS on admission was an independent predictor of in-hospital mortality (P=0.008). CONCLUSION: CS on admission patients have a worse outcome but benefit equally from emergency revascularization as delayed CS patients, emphasizing the need for rapid and direct access of CS on admission patients to facilities providing this care
— id: 64198, year: 2006, vol: 27, page: 664, stat: Journal Article,

Interhospital transfer for early revascularization in patients with ST-elevation myocardial infarction complicated by cardiogenic shock--a report from the SHould we revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) trial and registry
Jeger, Raban V; Tseng, Chi-Hong; Hochman, Judith S; Bates, Eric R
2006 Oct;152(4):686-692, American heart journal
BACKGROUND: Early revascularization (ERV) in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS) reduces mortality rates. Patients admitted to hospitals without revascularization capability have high mortality rates and are not often transferred for ERV. METHODS: Transfer and direct-admit patients with STEMI from the SHOCK Trial and Registry with left ventricular failure (N = 969) were analyzed to determine benefit of ERV in transfer patients. RESULTS: Transfer patients (46%) were younger and less likely to have prior hypertension, myocardial infarction, and heart failure. They received more aggressive treatment, were revascularized later after CS (median 7.3 vs 3.9 hours, P = .0002), and had similar adjusted inhospital mortality compared with direct-admit patients (55% vs 56%). Inhospital mortality was lower in ERV than no/late revascularization (41% vs 53%, P = .017 for transfer patients; 55% vs 71%, P = .0003 for direct-admit patients). Multiple logistic regression showed that inhospital mortality was associated with age (odds ratio [OR] 1.50 per decade increase, 95% CI 1.31-1.73, P < .0001), mean arterial pressure (OR 0.98 per 1 mm Hg increase, 95% CI 0.97-0.99, P < .0001), fibrinolysis before CS (OR 0.65, 95% CI 0.52-0.96, P = .040), and ERV (OR 0.70, 95% CI 0.52-0.96, P = .028), but not transfer admission (OR 1.23, 95% CI 0.86-1.74, P = .26). CONCLUSIONS: Despite longer time to treatment, transfer patients are a selected population with similar adjusted inhospital mortality and ERV benefit as direct-admit patients. Selected patients with STEMI and CS admitted to hospitals without revascularization capability should be transferred to centers with revascularization capability for immediate angiography
— id: 68940, year: 2006, vol: 152, page: 686, stat: Journal Article,

Improvement in stroke work index and stroke volume index, the most powerful serial hemodynamic variables in cardiogenic shock complicating acute myocardial infarction, should not delay early revascularization: A report from the SHOCK trial
Jeger, RV; Lowe, AM; Hochman, JS; Buller, CE; Dzavik, V; Webb, JG; Pfisterer, ME; LeJemtel, TH; Jorde, UP
2006 OCT 31 ;114(18):745-745, Circulation
— id: 69563, year: 2006, vol: 114, page: 745, stat: Journal Article,

Ethnic differences in rate, treatment and outcome of cardiogenic shock complicating ST segment elevation myocardial infarction - A report from the national registry of myocardial infarction
Jorapur, V; Pearte, C; Apolito, R; Frederick, PD; Babaev, A; Hochman, JS
2006 OCT 31 ;114(18):463-463, Circulation
— id: 69555, year: 2006, vol: 114, page: 463, stat: Journal Article,

Chronic kidney disease, ejection fraction and heart failure in patients with occluded infarct-related arteries post-myocardial infarction: Data from the occluded artery trial
Jorapur, V; Sadowski, Z; Reynolds, HR; Carvalho, AC; Buller, CE; Rankin, J; Renkin, J; Steg, PG; White, H; Vozzi, C; Balcells, E; Ragosta, M; Martin, CE; Tamis-Holland, JE; Srinivas, V; Wharton, W; Abramsky, S; Mon, AC; Barton, B; Lamas, GA; Hochman, JS
2006 OCT 31 ;114(18):404-404, Circulation
— id: 69553, year: 2006, vol: 114, page: 404, stat: Journal Article,

Clinical and coronary angiographic correlates of myocardial perfusion grade following late mechanical reperfusion of occluded infarct-related arteries post-myocardial infarction - a total occlusion study of canada-2 substudy
Jorapur, V; Steigen, T; Buller, CE; Dzavik, V; Webb, J; Strauss, BH; Yeoh, E; Kurray, P; Sokalski, L; Machado, M; Forman, S; Lamas, GA; Hochman, JS; Mancini, GJ
2006 OCT 31 ;114(18):348-348, Circulation
— id: 69552, year: 2006, vol: 114, page: 348, stat: Journal Article,

Restrictive physiology in cardiogenic shock: observations from echocardiography
Reynolds, Harmony R; Anand, Sumeet K; Fox, Justin M; Harkness, Shannon; Dzavik, Vladimir; White, Harvey D; Webb, John G; Gin, Kenneth; Hochman, Judith S; Picard, Michael H
2006 Apr;151(4):890.e9-890.15, American heart journal
BACKGROUND: Left ventricular diastolic abnormalities are associated with adverse outcome in myocardial infarction. Intra-aortic balloon pump (IABP) support is associated with improved diastolic filling. In the SHOCK trial and registry, average left ventricular ejection fraction (LVEF) was approximately 30%, higher than expected based on the classic paradigm. We hypothesized that restrictive physiology plays a role in cardiogenic shock (CS). METHODS: Echocardiograms obtained during the SHOCK trial within 24 hours of randomization were centrally interpreted. Patients with quantifiable mitral E-wave deceleration time were included (n = 64). The restrictive filling pattern was defined as deceleration time < 140 milliseconds. RESULTS: The restrictive pattern was seen in 60.9% of patients studied. Patients with this pattern had lower LVEF (31.1% vs 39.0%, P = .02) and higher wall motion score index (2.1 vs 1.8, P = .05). Patients with restriction were more likely to have IABP support during echocardiography (73.7% vs 43.5%, P = .03). There was no difference with and without restriction in demographic and hemodynamic variables or in mitral regurgitation degree or extent of coronary disease. The restrictive pattern had positive predictive value of 80% for pulmonary capillary wedge pressure > or = 20 mm Hg. Thirty-day survival was 53.9% with restriction versus 68.0% without restriction, P = .31. There was no difference in New York Heart Association class at 1 year between groups. CONCLUSIONS: The restrictive filling pattern is common in patients with CS, which may suggest that diastolic dysfunction contributes to CS pathogenesis. Patients with the restrictive pattern had lower LVEF despite IABP support. An association between the restrictive pattern and mortality was not demonstrated; power was limited by sample size
— id: 63840, year: 2006, vol: 151, page: 890.e9, stat: Journal Article,

Association of myocardial perfusion grade after late infarct reperfusion with baseline indices of global LV function; Analysis from the total occlusion study of Canada-2
Steigen, T; Jorapur, V; Buller, CE; Dzavik, V; Cardona, M; Almond, D; Brass, N; Burton, J; Zurakowski, A; Forman, S; Lamas, GA; Hochman, JS; Mancini, GBJ
2006 OCT 31 ;114(18):507-508, Circulation
— id: 69556, year: 2006, vol: 114, page: 507, stat: Journal Article,

Temporal trends in the use of early cardiac catheterization in patients with non-ST-segment elevation acute coronary syndromes (results from CRUSADE)
Tricoci, Pierluigi; Peterson, Eric D; Mulgund, Jyotsna; Newby, L Kristin; Saucedo, Jorge F; Kleiman, Neil S; Bhatt, Deepak L; Berger, Peter B; Cannon, Christopher P; Cohen, David J; Hochman, Judith S; Ohman, E Magnus; Gibler, W Brian; Harrington, Robert A; Smith, Sidney C Jr; Roe, Matthew T
2006 Nov 1;98(9):1172-1176, American journal of cardiology
We evaluated temporal trends in the use of early (<48 hours) catheterization in patients with non-ST-segment elevation acute coronary syndromes with respect to baseline risk features since publication of the American College of Cardiology/American Heart Association guidelines, which include a class IA recommendation for an early invasive strategy for high-risk patients with non-ST-segment elevation acute coronary syndromes. Overall, we found that early catheterization use increased from 53% to 61% during the 3 years after the guidelines were released, but the increased use of early catheterization was highest (11%) in the group that was at lowest risk of predicted mortality, and it was lowest (6%) in the group at highest risk of predicted mortality who would potentially receive the most benefit from an aggressive treatment approach. In conclusion, despite the overall increase in the use of early catheterization, the gap between the use of an early invasive strategy in the highest and lowest risk patients remains large and tends to increase over time
— id: 71984, year: 2006, vol: 98, page: 1172, stat: Journal Article,

Serial echocardiograms in patients with cardiogenic shock: Analysis of the SHOCK trial
Yehudai, L; Reynolds, HR; Schwarz, SA; Harkness, SM; Picard, MH; Davidoff, R; Hochman, JS
2006 FEB 21 ;47(4):111A-111A, Journal of the American College of Cardiology
— id: 63301, year: 2006, vol: 47, page: 111A, stat: Journal Article,

Sex differences in glycoprotein llb/llla inhibitor dosing and bleeding in acute coronary syndromes: Results from CRUSADE
Alexander, KP; Chen, AY; Roe, MT; Newby, LK; Gibson, CM; Schwartz, J; Hochman, JS; Redberg, RF; Ohman, EM; Gibler, WB; Peterson, ED
2005 OCT 25 ;112(17):U491-U492, Circulation
— id: 60205, year: 2005, vol: 112, page: U491, stat: Journal Article,

Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock
Babaev, Anvar; Frederick, Paul D; Pasta, David J; Every, Nathan; Sichrovsky, Tina; Hochman, Judith S
2005 Jul 27;294(4):448-454, JAMA
CONTEXT: Early mechanical revascularization in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock is a therapeutic strategy that reduces mortality. It has been a class I recommendation in guidelines from the American College of Cardiology and the American Heart Association since 1999 for patients younger than 75 years. However, little is known about implementation of these guidelines in practice. OBJECTIVES: To assess trends in early revascularization and mortality for patients with cardiogenic shock complicating AMI and to determine whether the national guidelines affect revascularization rates. DESIGN, SETTING, AND PATIENTS: Prospective, observational study of 293,633 patients with ST-elevation myocardial infarction (25,311 [8.6%] had cardiogenic shock; 7356 [29%] had cardiogenic shock at hospital presentation) enrolled in the National Registry of Myocardial Infarction (NRMI) from January 1995 to May 2004 at 775 US hospitals with revascularization capability (defined as the capability to perform cardiac catheterization, percutaneous coronary intervention [PCI], and open-heart surgery). MAIN OUTCOME MEASURES: Management patterns and in-hospital mortality rates. RESULTS: There was an increase in primary PCI rates from 27.4% to 54.4% (P<.001) in hospitals with revascularization capability that paralleled the change in PCI for ST-elevation myocardial infarction. There was no significant change in rates of immediate coronary artery bypass graft surgery (from 2.1% to 3.2%). Propensity-adjusted multivariable analyses demonstrated that primary PCI was associated with a decreased odds of death during hospitalization (odds ratio, 0.46; 95% confidence interval, 0.40-0.53). There were no differences in the rates of change in revascularization rates based on the date when the guidelines were released regardless of patient age. Overall in-hospital cardiogenic shock mortality decreased from 60.3% in 1995 to 47.9% in 2004 (P<.001). CONCLUSIONS: The use of PCI for patients with cardiogenic shock was associated with improved survival in a large group of hospitals with revascularization capability. The American College of Cardiology and American Heart Association guidelines had no detectable temporal impact on revascularization rates. These findings support the need for increased adherence to these guidelines
— id: 56376, year: 2005, vol: 294, page: 448, stat: Journal Article,

Gender disparities in the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: large-scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative
Blomkalns, Andra L; Chen, Anita Y; Hochman, Judith S; Peterson, Eric D; Trynosky, Kelly; Diercks, Deborah B; Brogan, Gerard X Jr; Boden, William E; Roe, Matthew T; Ohman, E Magnus; Gibler, W Brian; Newby, L Kristin
2005 Mar 15;45(6):832-837, Journal of the American College of Cardiology
OBJECTIVES: We hypothesized that significant disparities in gender exist in the management of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS). BACKGROUND: Gender-related differences in the diagnosis and treatment of ACS have important healthcare implications. No large-scale examination of these disparities has been completed since the publication of the revised American College of Cardiology/American Heart Association guidelines for management of patients with NSTE ACS. METHODS: Using data from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative, we examined differences of gender in treatment and outcomes among patients with NSTE ACS. RESULTS: Women (41% of 35,875 patients) were older (median age 73 vs. 65 years) and more often had diabetes and hypertension. Women were less likely to receive acute heparin, angiotensin-converting enzyme inhibitors, and glycoprotein IIb/IIIa inhibitors and less commonly received aspirin, angiotensin-converting enzyme inhibitors, and statins at discharge. The use of cardiac catheterization and revascularization was higher in men, but among patients with significant coronary disease, percutaneous revascularization was performed in a similar proportion of women and men. Women were at higher risk for unadjusted in-hospital death (5.6% vs. 4.3%), reinfarction (4.0% vs. 3.5%), heart failure (12.1% vs. 8.8%), stroke (1.1% vs. 0.8%), and red blood cell transfusion (17.2% vs. 13.2%), but after adjustment, only transfusion was higher in women. CONCLUSIONS: Despite presenting with higher risk characteristics and having higher in-hospital risk, women with NSTE ACS are treated less aggressively than men
— id: 72007, year: 2005, vol: 45, page: 832, stat: Journal Article,

An early invasive strategy in women who present with high-risk non-ST-segment elevation acute coronary syndromes is associated with more aggressive pharmacotherapy and better in-hospital outcomes: Results from the CRUSADE improvement initiative
Boden, WE; Dada, M; Lundbye, J; Roe, MT; Peterson, ED; Newby, LK; Milford-Beland, S; Redberg, R; Hochman, JS; Diercks, DB; Gibler, WB; Ohman, EM
2005 OCT 25 ;112(17):U808-U808, Circulation
— id: 60212, year: 2005, vol: 112, page: U808, stat: Journal Article,

Sex-related differences in in-hospital clinical outcomes among high-risk non-ST-segment elevation acute coronary syndrome patients undergoing percutaneous coronary intervention: Results from the CRUSADE quality improvement initiative
Boden, WE; Elkoustaf, RA; Dada, M; Roe, MT; Peterson, ED; Newby, LK; Milford-Beland, S; Redberg, R; Hochman, JS; Diercks, DB; Gibler, WB; Smith, SC; Ohman, EM
2005 OCT 25 ;112(17):U378-U378, Circulation
— id: 60204, year: 2005, vol: 112, page: U378, stat: Journal Article,

The relationship between baseline risk and mortality in ST-elevation acute myocardial infarction treated with pharmacological reperfusion: insights from the Global Utilization of Strategies To open Occluded arteries (GUSTO) V trial
Brener, Sorin J; Lincoff, A Michael; Bates, Eric R; Jia, Gang; Armstrong, Paul W; Guetta, Victor; Hochman, Judith S; Savonitto, Stefano; Wilcox, Robert G; White, Harvey D; Topol, Eric J
2005 Jul;150(1):89-93, American heart journal
BACKGROUND: We studied the potential interaction between baseline risk of death and treatment with either standard fibrinolytic monotherapy or combination fibrin and platelet lysis with respect to outcome of patients with ST-elevation myocardial infarction (STEMI) enrolled in the Global Utilization of Strategies To open Occluded arteries (GUSTO) V trial. METHODS: Using the Thrombolysis in Myocardial Infarction (TIMI) risk score (0-14 points) for STEMI, we analyzed the 30-day and 1-year mortality according to treatment assignment and risk category. Multivariable analysis was performed to identify the potential interactions between treatment and baseline risk. RESULTS: The TIMI risk score could be calculated in 16256 patients (98% of patients enrolled). The median score was 2 (1-4) in each treatment group (P = .07). The risk score was significantly associated with 30-day mortality (hazard ratio [HR], 1.52; 95% CI 1.47-1.56, P < .001, for each additional 1 point), as well as with 1-year mortality (HR 1.51, CI 1.47-1.55, P < .001). The treatment allocation was not significantly related to mortality, and there was no significant interaction between baseline risk score and treatment with respect to either end point. Although combination therapy significantly reduced death or reinfarction at 7 days (HR 0.69, CI 0.54-0.89, P < .01), independent of the risk score, there was no significant statistical interaction between the two (P = .29). CONCLUSION: The TIMI risk score accurately predicted early and 1-year mortality in patients with STEMI treated with pharmacological reperfusion. We did not identify any heterogeneity in the response of patients to combination therapy according to their TIMI risk score
— id: 71997, year: 2005, vol: 150, page: 89, stat: Journal Article,

Outcome of patients aged >or=75 years in the SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK (SHOCK) trial: do elderly patients with acute myocardial infarction complicated by cardiogenic shock respond differently to emergent revascularization?
Dzavik, Vladimir; Sleeper, Lynn A; Picard, Michael H; Sanborn, Timothy A; Lowe, April M; Gin, Ken; Saucedo, Jorge; Webb, John G; Menon, Venu; Slater, James N; Hochman, Judith S
2005 Jun;149(6):1128-1134, American heart journal
BACKGROUND: In the SHOCK trial, the group of patients aged >or=75 years did not appear to derive the mortality benefit from early revascularization (ERV) versus initial medical stabilization (IMS) that was seen in patients aged <75 years. We sought to determine the reason for this finding by examining the baseline characteristics and outcomes of the 2 treatment groups by age. METHODS: Patients with cardiogenic shock (CS) secondary to left ventricular (LV) failure were randomized to ERV within 6 hours or to a period of IMS. We compared the characteristics by treatment group of patients aged >or=75 years and of their younger counterparts. RESULTS: Of the 56 enrolled patients aged >or=75 years, those assigned to ERV had lower LV ejection fraction at baseline than IMS-assigned patients (27.5% +/- 12.7% vs 35.6% +/- 11.6%, P = .051). In the elderly ERV and IMS groups, 54.2% and 31.3%, respectively, were women ( P = .105) and 62.5% and 40.6%, respectively, had an anterior infarction (P = .177). The 30-day mortality rate in the ERV group was 75.0% in patients aged >or=75 years and 41.4% in those aged <75 years. In the IMS group, 30-day mortality was 53.1% for those aged >or=75 years, similar to the 56.8% for patients aged <75 years. CONCLUSIONS: Overall, the elderly randomized to ERV did not have better survival than elderly IMS patients. Despite the strong association of age and death post-CS, elderly patients assigned to IMS had a 30-day mortality rate similar to that of IMS patients aged <75 years, suggesting that this was a lower-risk group with more favorable baseline characteristics. The lack of apparent benefit from ERV in elderly patients in the SHOCK trial may thus be due to differences in important baseline characteristics, specifically LV function, and play of chance arising from the small sample size. Therefore, the SHOCK trial overall finding of a 12-month survival benefit for ERV should be viewed as applicable to all patients, including those >or=75 years of age, with acute myocardial infarction complicated by CS
— id: 72003, year: 2005, vol: 149, page: 1128, stat: Journal Article,

Elevated body mass index and intermediate-term clinical outcomes after acute coronary syndromes
Eisenstein, Eric L; McGuire, Darren K; Bhapkar, Manjushri V; Kristinsson, Arni; Hochman, Judith S; Kong, David F; Califf, Robert M; Van de Werf, Frans; Yancy, William S Jr; Newby, L Kristin
2005 Sep;118(9):981-990, American journal of medicine
PURPOSE: Obesity is a coronary disease risk factor, but its independent effect on clinical outcomes following acute coronary syndromes has not been quantified. We evaluated the relationship between elevated body mass index (BMI) and 30-day, 90-day, and 1-year clinical outcomes postacute coronary syndromes. SUBJECTS AND METHODS: Using 15 071 patients (normal weight [BMI = 18.5-24.9 kg/m(2)], overweight [BMI = 25-29.9 kg/m(2)], obese [BMI = 30-34.9 kg/m(2)] or very obese [BMI > or =35 kg/m(2)]) randomized from 1997-1999 in the SYMPHONY (Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes) and 2nd SYMPHONY trials, we evaluated the relationships between BMI and 30-day, 90-day, and 1-year mortality and 30-day and 90-day death or myocardial infarction. RESULTS: Increasing BMI was associated with younger age, multiple comorbidities, and greater cardiac medication and procedure use; however, systolic function and coronary disease extent were similar for all BMI categories. Unadjusted Kaplan-Meier mortality estimates were higher for normal-weight patients than for all other BMI groups. After multivariable adjustment, the 30-day mortality hazard ratios (95% confidence interval [CI]) were: overweight, 0.66 (95% CI: 0.47 to 0.94); obese, 0.61 (95% CI: 0.39 to 0.97); very obese, 0.89 (95% CI: 0.48 to 1.64). Adjusted hazard ratios were similar for 90-day and 1-year mortality. There were no statistically significant differences among BMI groups in 30-day and 90-day death or myocardial infarction (unadjusted or adjusted). CONCLUSION: Overweight and obese BMI classifications were associated with better intermediate-term survival after acute coronary syndromes than normal weight and very obese, but death or myocardial infarction rates were similar. Further study is required to understand the apparent association of overweight and moderate obesity with better intermediate-term outcomes
— id: 71996, year: 2005, vol: 118, page: 981, stat: Journal Article,

Drop in glucose level following acute myocardial intarction predicts improved survival in nondiabetic patients, regardless of baseline glucose level
Goyal, A; Mahaffey, KW; Gang, J; Pieper, K; Nicolau, JC; Armstrong, PW; Hochman, JS; Weaver, WD; Ruzyllo, W; Peterson, JL; Theroux, P; Todaro, TG; Mojcik, CF; Granger, CB
2005 OCT 25 ;112(17):U846-U846, Circulation
— id: 60213, year: 2005, vol: 112, page: U846, stat: Journal Article,

Design and methodology of the Occluded Artery Trial (OAT)
Hochman, Judith S; Lamas, Gervasio A; Knatterud, Genell L; Buller, Christopher E; Dzavik, Vladimir; Mark, Daniel B; Reynolds, Harmony R; White, Harvey D
2005 Oct;150(4):627-642, American heart journal
Experimental and clinical studies have suggested that late opening of an infarct-related artery (IRA) after myocardial infarction (MI) could improve clinical outcome. However, the suggestive observational data are limited by selection biases. Indeed, most small randomized studies have not demonstrated benefit. Thus, there is no recommendation for routine late opening of the IRA in current national guidelines for management of stable post-MI patients. The OAT is designed to test the hypothesis that opening a totally occluded IRA 3 to 28 days after MI in high-risk asymptomatic patients will improve clinical outcome and be cost-effective. The primary end point is the first occurrence of recurrent MI, hospitalization/treatment of New York Heart Association class IV congestive heart failure, or death. Trial background, design, and preliminary baseline characteristics of 2027 randomized patients are presented. Eligible patients are randomly assigned in equal proportions to optimal evidence-based medical care or optimal care plus late opening of the IRA using percutaneous coronary intervention of the occluded IRA. Treatment groups will be compared using intent-to-treat analysis. The results of OAT should have broad clinical impact by defining an evidence-based approach to the asymptomatic, high-risk, post-MI patient with an occluded IRA. If the efficacy and cost-effectiveness of percutaneous coronary intervention are established, then a policy of routinely seeking and opening persistently occluded IRAs could be advocated. If not, this strategy should be avoided in this large subgroup of post-MI patients
— id: 66474, year: 2005, vol: 150, page: 627, stat: Journal Article,

Systemic inflammatory response syndrome after acute myocardial infarction complicated by cardiogenic shock
Kohsaka, Shun; Menon, Venu; Lowe, April M; Lange, Michael; Dzavik, Vladimir; Sleeper, Lynn A; Hochman, Judith S
2005 Jul 25;165(14):1643-1650, Archives of internal medicine
BACKGROUND: The role of inflammation in patients with coronary artery disease is emerging. We sought to assess the profile and outcomes of patients with a clinical syndrome of severe systemic inflammation that led to a diagnosis of suspected sepsis in the setting of acute myocardial infarction complicated by cardiogenic shock (CS). METHODS: Patients enrolled in the randomized SHOCK (SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK) trial (n = 302) were divided into those with clinical signs of severe systemic inflammation (eg, fever [94%] or leukocytosis [72%]) that led to a diagnosis of suspected sepsis (n = 54 [18%]) and those without suspected sepsis (controls; n = 243 [80%]). The patients with suspected sepsis were then further subdivided into those who were considered to be potentially infectious (positive culture result ['culture-positive']; n = 40) and those who were not (negative culture result ['culture-negative']; n = 14). RESULTS: Severe systemic inflammation was diagnosed 4 and 2 days after the onset of CS in culture-positive and culture-negative patients, respectively. Patients who developed systemic inflammation tended to be younger (P = .05) and to have lower systemic vascular resistance (SVR) near the onset of CS (P = .006). Many culture-positive patients (40%) had undergone coronary artery bypass graft surgery. However, the lower the initial SVR, the higher the risk of developing culture-positive systemic inflammation (P = .01), even after controlling for age and coronary artery bypass graft surgery. A time-dependent model, adjusted for age, showed that culture-positive patients were at significantly higher risk for death than were controls (hazard ratio, 2.22; 95% confidence interval, 1.32-3.76; P = .008). CONCLUSIONS: Almost one fifth of patients with acute myocardial infarction complicated by CS showed clinical signs of severe systemic inflammation, and those who were culture-positive for sepsis had twice the risk of death. The observation of lower SVR at the onset of shock in patients who subsequently had culture-positive systemic inflammation suggests that inappropriate vasodilation may play an important role in the pathogenesis and persistence of shock and in the risk of infection
— id: 71998, year: 2005, vol: 165, page: 1643, stat: Journal Article,

Percutaneous coronary intervention and adjunctive pharmacotherapy in women: a statement for healthcare professionals from the American Heart Association
Lansky, Alexandra J; Hochman, Judith S; Ward, Patricia A; Mintz, Gary S; Fabunmi, Rosalind; Berger, Peter B; New, Gishel; Grines, Cindy L; Pietras, Cody G; Kern, Morton J; Ferrell, Margaret; Leon, Martin B; Mehran, Roxana; White, Christopher; Mieres, Jennifer H; Moses, Jeffrey W; Stone, Gregg W; Jacobs, Alice K
2005 Feb 22;111(7):940-953, Circulation
More than 1.2 million percutaneous coronary interventions are performed annually in the United States, with only an estimated 33% performed in women, despite the established benefits of percutaneous coronary intervention and adjunctive pharmacotherapy in reducing fatal and nonfatal ischemic complications in acute myocardial infarction and high-risk acute coronary syndromes. This statement reviews sex-specific data on the safety and efficacy of contemporary interventional therapies in women
— id: 68798, year: 2005, vol: 111, page: 940, stat: Journal Article,

Cardiogenic shock: predictors of outcome based on right and left ventricular size and function at presentation
Mendes, Lisa A; Picard, Michael H; Sleeper, Lynn A; Thompson, Christopher R; Jacobs, Alice K; White, Harvey D; Hochman, Judith S; Davidoff, Ravin
2005 Jun;16(4):209-215, Coronary artery disease
OBJECTIVE: To determine the characteristics and prognostic importance of right ventricular (RV) dilatation and dysfunction in patients with cardiogenic shock secondary to left ventricular (LV) dysfunction enrolled in the Should we emergently revascularize occluded coronaries for cardiogenic shock (SHOCK) trial. METHODS: LV and RV size and function were quantified by echocardiography in 99 patients with cardiogenic shock secondary to predominant LV dysfunction. RESULTS: For all patients, RV dysfunction was not associated with a poor 1-year survival. When the 59 patients with RV dysfunction were stratified into two morphologic groups based upon LV-to-RV end-diastolic area ratio (LV/RV) < or >or=2, the presence of disproportionate RV enlargement (LV/RV <2) was associated with inferior myocardial infarction (80%) and right coronary artery culprit disease (79%). In contrast, the index myocardial infarction in patients with predominant LV enlargement (LV/RV >or=2) was anterior (69%) and associated with left anterior descending artery disease (64%). Patients with LV/RV <2 had significantly higher right atrial pressures (20.1+/-5.2 compared with 14.5+/-8.9 mmHg, P=0.001) and lower RV fractional area change (20.4+/-8.7 compared with 33.5+/-11.0%, P=0.0001), heart rate (87+/-21 compared with 106+/-23 beats/min, P=0.006) and cardiac index (1.5+/-0.5 compared with 2.0 +/-0.9 l/min per m, P=0.007) than patients with LV/RV >or=2. Despite the hemodynamic profile and severity of RV dysfunction in the LV/RV <2 group, 12-month survival was significantly greater in these patients (70% LV/RV <2 compared with 34% LV/RV >or=2, P=0.027). CONCLUSIONS: In patients with cardiogenic shock secondary to predominant LV failure, the presence of RV dilatation and dysfunction identifies a subgroup of patients with predominant inferior myocardial infarction and an improved long-term prognosis
— id: 72004, year: 2005, vol: 16, page: 209, stat: Journal Article,

Prognostic implication of activated partial thromboplastin time after reteplase or half-dose reteplase plus abciximab: results from the GUSTO-V trial
Nallamothu, Brahmajee K; Bates, Eric R; Hochman, Judith S; Granger, Christopher B; Guetta, Victor; Wilcox, Robert G; White, Harvey D; Armstrong, Paul W; Savonitto, Stefano; Jia, Gang; Lincoff, A Michael; Topol, Eric J
2005 Aug;26(15):1506-1512, European heart journal
AIMS: To evaluate the relationship between activated partial thromboplastin time (aPTT) and clinical outcomes in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-V) trial comparing standard-dose reteplase to half-dose reteplase and abciximab. METHODS AND RESULTS: We analysed data on 11,420 patients receiving unfractionated heparin. Peak aPTT levels recorded during the hospitalization were correlated with clinical outcomes. Multivariable logistic regression models examined the relationship between peak aPTT levels and (i) moderate-to-severe bleeding, (ii) intracerebral haemorrhage, (iii) reinfarction, and (iv) 30-day mortality. Non-linear relationships were explored in the models using cubic spline functions. Higher rates of significant complications were seen in both groups when aPTT levels were <50 s or when levels were >70 s. In the combination therapy group, the relationship between aPTT levels and bleeding appeared accentuated. Reinfarction rates increased gradually as aPTT levels were >70 s in both groups, but the relationships were not statistically significant. Peak aPTT levels <50 s were associated with increased 30-day mortality even after multivariable adjustment. CONCLUSION: Peak aPTT levels <50 s and >70 s are associated with worse clinical outcomes in the modern era of fibrinolytic therapy; these relationships are different in patients receiving standard reteplase vs. combination therapy
— id: 72006, year: 2005, vol: 26, page: 1506, stat: Journal Article,

Racial and ethnic differences in the treatment and outcome of cardiogenic shock following acute myocardial infarction
Palmeri, Sebastian T; Lowe, April M; Sleeper, Lynn A; Saucedo, Jorge F; Desvigne-Nickens, Patrice; Hochman, Judith S
2005 Oct 15;96(8):1042-1049, American journal of cardiology
We investigated the association between race/ethnicity on the use of cardiac resources in patients who have acute myocardial infarction that is complicated by cardiogenic shock. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial examined the effect of reperfusion and revascularization treatment strategies on mortality. Patients screened but not enrolled in the SHOCK Trial (n = 1,189) were entered into the SHOCK registry. Of the patients in the United States registry (n = 538) who had shock due to predominant left ventricular failure, 440 were characterized as white (82%), 42 as Hispanic (8%), 34 as African-American (6%), and 22 as Asian/other (4%). The use of invasive procedures differed significantly by race/ethnicity. Hispanic patients underwent coronary angiography significantly less often than did white patients (38 vs 66%, p = 0.002). Among those patients who underwent coronary angiography, there were no race/ethnicity differences in the proportion of patients who underwent revascularization (p = 0.353). Overall in-hospital mortality (57%) differed significantly by race/ethnicity (p = 0.05), with the highest mortality rate in Hispanic patients (74% vs 65% for African-Americans, 56% for whites, and 41% for Asian/other). After adjustment for patient characteristics and use of revascularization, there were no mortality differences by race/ethnicity (p = 0.262), with all race/ethnicity subgroups benefiting equally by revascularization. In conclusion, the SHOCK registry showed significant differences in the treatment and in-hospital mortality of Hispanic patients who had cardiogenic shock, with these patients being less likely to undergo percutaneous coronary intervention. Therefore, early revascularization should be strongly considered for all patients, independent of race/ethnicity, who develop cardiogenic shock after acute myocardial infarction
— id: 71994, year: 2005, vol: 96, page: 1042, stat: Journal Article,

Prognostic usefulness of white blood cell count and temperature in acute myocardial infarction (from the CARDINAL Trial)
Patel, Manesh R; Mahaffey, Kenneth W; Armstrong, Paul W; Weaver, W Douglas; Tasissa, Gudaye; Hochman, Judith S; Todaro, Thomas G; Malloy, Kevin J; Rollins, Scott; Theroux, Pierre; Ruzyllo, Witold; Nicolau, Jose C; Granger, Christopher B
2005 Mar 1;95(5):614-618, American journal of cardiology
White blood cell (WBC) count and temperature are 2 global measures of inflammation that are systematically gathered and easily identifiable in a clinical setting, unlike many other markers of inflammation being investigated in patients with coronary artery disease. The prognostic usefulness of the WBC count and temperature were evaluated in a large acute myocardial infarction trial, the Complement And ReDuction of INfarct size after Angioplasty or Lytics program. Baseline and serial measurements of WBC counts and temperature were correlated with infarct size and clinical outcome
— id: 72008, year: 2005, vol: 95, page: 614, stat: Journal Article,

Sex differences in presentation with persistent total occlusion after acute
Ramanathan, K; Atchison, D; Abramsky, S; Mon, A; Tunesi, AM; Forman, SA; Hochman, JS; Reynolds, H
2005 SEP ;26(3):245-246, European heart journal
— id: 69535, year: 2005, vol: 26, page: 245, stat: Journal Article,

Renal function, concomitant medication use and outcomes following acute coronary syndromes
Reddan, Donal N; Szczech, Lynda; Bhapkar, Manjushri V; Moliterno, David J; Califf, Robert M; Ohman, E Magnus; Berger, Peter B; Hochman, Judith S; Van de Werf, Frans; Harrington, Robert A; Newby, L Kristin
2005 Oct;20(10):2105-2112, Nephrology, dialysis, transplantation
BACKGROUND: Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes. METHODS: Patients were stratified by CKD stage using creatinine clearance (CrCl, ml/min) estimated by the modified MDRD equation using baseline core laboratory creatinine measures. Serum creatinine > or =1.5 mg/dl was an exclusion criterion for the SYMPHONY trials. Baseline characteristics and outcomes across CKD categories were compared and Cox proportional hazards regression was used to assess the relationship of renal insufficiency with clinical outcomes after adjusting for previously identified outcome predictors. Interactions between the use of specific medications and calculated CrCl were tested in the final Cox proportional hazards model predicting time to mortality. RESULTS: Of 13 707 patients analysed, 6840 had CKD stage I (CrCl > or =90 ml/min), 5909 stage II (CrCl 60-89 ml/min), 955 stage III (CrCl 30-59 ml/min) and three stage IV (CrCl <30 ml/min). Patients with more advanced CKD (III) were older, more often female, non-smokers and more likely to have co-morbid diseases including diabetes mellitus, hypertension and congestive heart failure. Cardiovascular medications were used less frequently in patients with CKD. Unadjusted survival was poorer in patients with CKD stages > or =II. In adjusted analyses, for those with CrCl < or =91, each 10 ml/min increase in CrCl was associated with a significantly decreased risk of mortality (hazards ratio 0.897, 95% confidence interval 0.815-0.986) (P = 0.024). The interaction between use of angiotensin-converting enzyme (ACE) inhibitors and CrCl was significantly associated with outcomes; the benefit of drug therapy was greater among patients with CKD. CONCLUSIONS: CKD is an independent predictor of risk among ACS patients, and is associated with less frequent use of proven medical therapies. More aggressive use of conventional cardiovascular therapies in patients with CKD and ACS may be warranted
— id: 71999, year: 2005, vol: 20, page: 2105, stat: Journal Article,

Functional status and quality of life after emergency revascularization for cardiogenic shock complicating acute myocardial infarction
Sleeper, Lynn A; Ramanathan, Krishnan; Picard, Michael H; Lejemtel, Thierry H; White, Harvey D; Dzavik, Vladimir; Tormey, Deborah; Avis, Nancy E; Hochman, Judith S
2005 Jul 19;46(2):266-273, Journal of the American College of Cardiology
OBJECTIVES: Our goal was to describe the functional status of cardiogenic shock survivors, identify the correlates of cardiogenic shock, and compare global quality of life and functional status of patients randomly assigned to treatment with emergency revascularization (ERV) versus initial medical stabilization (IMS). BACKGROUND: Historically, the hospital survival rate of patients with cardiogenic shock complicating acute myocardial infarction (MI) has been very low. Shock survivors are salvaged from a critically ill state, and their later functional status is not well documented. The SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial showed significantly improved one-year survival after ERV compared with IMS. METHODS: The SHOCK trial survivors completed interviews at 2 weeks after discharge and at 6 and 12 months after MI. Functional status assessment included the Multidimensional Index of Life Quality and New York Heart Association (NYHA) congestive heart failure functional class. RESULTS: Eighty-seven percent of one-year survivors of the SHOCK trial were in NYHA functional class I or II. Between two weeks after discharge and one year after MI, improvement was similar in the two treatment groups (18% overall), but fewer patients remained stable (44% vs. 71%), and more patients worsened or died (34% vs. 15%) in the IMS group compared with those assigned to ERV. Assignment to ERV was the only independent predictor of outcome at one year. CONCLUSIONS: Although one-year mortality after ERV is still high (54%), most survivors have good functional status. The ERV patients have a lower rate of deterioration than IMS patients. The level of recovery for shock patients undergoing ERV is similar to that of historical controls not in cardiogenic shock undergoing elective revascularization
— id: 72001, year: 2005, vol: 46, page: 266, stat: Journal Article,

Prognostic significance of blood markers of inflammation in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty and effects of pexelizumab, a C5 inhibitor: a substudy of the COMMA trial
Theroux, Pierre; Armstrong, Paul W; Mahaffey, Kenneth W; Hochman, Judith S; Malloy, Kevin J; Rollins, Scott; Nicolau, Jose C; Lavoie, Joel; Luong, The Minh; Burchenal, Jeb; Granger, Christopher B
2005 Oct;26(19):1964-1970, European heart journal
AIMS: Pexelizumab, a monoclonal antibody inhibiting C5, reduced 90 day mortality and shock in the COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA) trial without apparent reductions in infarct size. Inflammation is a critical component of ST-elevation myocardial infarction (STEMI); this substudy examines prognostic values of selected markers and treatment effects. METHODS AND RESULTS: C-reactive protein, interleukin-6 (IL-6), and tumour necrosis factor-alpha (TNF-alpha) serum levels were assessed in 337 patients enrolled in either the placebo or the pexelizumab 24 h infusion group. Higher C-reactive protein and IL-6 levels at baseline, 24 h, and 72 h were strongly associated with increased subsequent death (P<0.002 at baseline and 24 h, P<0.02 at 72 h); and all baseline marker levels with death or cardiogenic shock (P<0.03) within 90 days. C-reactive protein and IL-6 levels were similar at baseline, but significantly lower 24 h later with pexelizumab, when compared with placebo (17.1 vs. 25.5 mg/L, P=0.03 and 51.0 vs. 63.8 pg/mL, P=0.04, respectively). At 72 h, corresponding levels were similar, whereas TNF-alpha was slightly higher (P=0.04) in the treated group. CONCLUSION: Inflammation markers and their serial changes predict death and shock in patients with STEMI undergoing primary angioplasty. Pexelizumab reduced C-reactive protein and IL-6, suggesting treatment benefits mediated through anti-inflammatory effects
— id: 72005, year: 2005, vol: 26, page: 1964, stat: Journal Article,

Trends for utilization of early cardiac catheterization for non-ST-segment elevation acute coronary syndromes by patient risk status in the CRUSADE quality improvement initiative
Tricoci, P; Mulgund, J; Harrington, RA; Newby, LK; Saucedo, J; Kleiman, N; Bhatt, DL; Berger, P; Cannon, CP; Cohen, DJ; Hochman, JS; Gibler, WB; Ohman, EM; Peterson, ED; Smith, SC; Roe, MT
2005 OCT 25 ;112(17):U807-U807, Circulation
— id: 60211, year: 2005, vol: 112, page: U807, stat: Journal Article,

Integrating complementary medicine into cardiovascular medicine. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine)
Vogel, John H K; Bolling, Steven F; Costello, Rebecca B; Guarneri, Erminia M; Krucoff, Mitchell W; Longhurst, John C; Olshansky, Brian; Pelletier, Kenneth R; Tracy, Cynthia M; Vogel, Robert A; Vogel, Robert A; Abrams, Jonathan; Anderson, Jeffrey L; Bates, Eric R; Brodie, Bruce R; Grines, Cindy L; Danias, Peter G; Gregoratos, Gabriel; Hlatky, Mark A; Hochman, Judith S; Kaul, Sanjiv; Lichtenberg, Robert C; Lindner, Jonathan R; O'Rourke, Robert A; Pohost, Gerald M; Schofield, Richard S; Shubrooks, Samuel J; Tracy, Cynthia M; Winters, William L Jr
2005 Jul 5;46(1):184-221, Journal of the American College of Cardiology
— id: 72002, year: 2005, vol: 46, page: 184, stat: Journal Article,

Acute administration of angiotensin converting enzyme inhibitors in thrombolysed myocardial infarction patients is associated with a decreased incidence of heart failure, but an increased re-infarction risk
Voors, Adriaan A; de Kam, Pieter J; van den Berg, Maarten P; Borghi, Claudio; Hochman, Judith S; van Veldhuisen, Dirk J; van Gilst, Wiek H
2005 Mar;19(2):119-124, Cardiovascular drugs & therapy
INTRODUCTION: Ventricular remodeling starts very early after the onset of an acute myocardial infarction (AMI), and can be prevented by ACE-inhibitors. However, very limited data are available on the effect of acute (< 9 hours) treatment with angiotensin converting enzyme (ACE) inhibitors after an AMI on mortality, heart failure and re-infarction. The aim of the present study was to evaluate the effects of acute ACE-inhibitor treatment. METHODS: We performed a pooled analysis of three very similar randomized, placebo-controlled multi-center trials. In 845 thrombolysed patients with mainly first anterior MI, patients were randomised to acute ACE-inhibitor treatment (< 9 hours after MI) or placebo. RESULTS: After acute ACE-inhibitor treatment we observed similar 3-months mortality rates, and a significant reduction in the incidence of 3-months heart failure (26.1 vs. 19.3%; RR 0.67; 95% CI 0.45-1.0) as compared to placebo. In contrast, acute ACE-inhibitor treatment was associated with a significant 2.0 times increased 3-months re-infarction risk (7.0 vs. 3.6%; RR 2.0; 95% CI 1.1 to 3.8). Subgroup-analysis showed that patients with small infarct sizes treated with acute ACE-inhibitor (peak CPK < 1000 IU) had a 7.6 times higher re-infarction risk (95% CI 1.7 to 33) than patients with small infarctions treated with placebo. CONCLUSIONS: Acute ACE-inhibitor treatment in thrombolysed patients with mainly first anterior AMI resulted in a reduction of heart failure and similar mortality, but an increase in re-infarction rates, especially in patients with small infarct sizes. These results warrant caution for the very early use of ACE-inhibitors in smaller infarctions, although this needs to be confirmed in a larger prospective randomised clinical trial
— id: 72000, year: 2005, vol: 19, page: 119, stat: Journal Article,

Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial
White, Harvey D; Assmann, Susan F; Sanborn, Timothy A; Jacobs, Alice K; Webb, John G; Sleeper, Lynn A; Wong, Cheuk-Kit; Stewart, James T; Aylward, Philip E G; Wong, Shing-Chiu; Hochman, Judith S
2005 Sep 27;112(13):1992-2001, Circulation
BACKGROUND: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial demonstrated the survival advantage of emergency revascularization versus initial medical stabilization in patients developing cardiogenic shock after acute myocardial infarction. The relative merits of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with shock have not been defined. The objective of this analysis was to compare the effects of PCI and CABG on 30-day and 1-year survival in the SHOCK trial. METHODS AND RESULTS: Of the 302 trial patients, 128 with predominant left ventricular failure had emergency revascularization. The selection of revascularization procedures was individualized. Eighty-one patients (63.3%) had PCI, and 47 (36.7%) had CABG. The median time from randomization to intervention was 0.9 hours (interquartile range [IQR], 0.3 to 2.2 hours) for PCI and 2.7 hours (IQR, 1.3 to 5.5 hours) for CABG. Baseline demographics and hemodynamics were similar, except that there were more diabetics (48.9% versus 26.9%; P=0.02), 3-vessel disease (80.4% versus 60.3%; P=0.03), and left main coronary disease (41.3% versus 13.0%; P=0.001) in the CABG group. In the PCI group, 12.3% had 2-vessel and 2.5% had 3-vessel interventions. In the CABG group, 84.8% received > or =2 grafts, 52.2% received > or =3 grafts, and 87.2% were deemed completely revascularized. The survival rates were 55.6% in the PCI group compared with 57.4% in the CABG group at 30 days (P=0.86) and 51.9% compared with 46.8%, respectively, at 1 year (P=0.71). CONCLUSIONS: Among SHOCK trial patients randomized to emergency revascularization, those treated with CABG had a greater prevalence of diabetes and worse coronary disease than those treated with PCI. However, survival rates were similar. Emergency CABG is an important component of an optimal treatment strategy in patients with cardiogenic shock, and should be considered a complementary treatment option in patients with extensive coronary disease
— id: 71995, year: 2005, vol: 112, page: 1992, stat: Journal Article,

Initial experience with factor-Xa inhibition in percutaneous coronary intervention: the XaNADU-PCI Pilot
Alexander, J H; Dyke, C K; Yang, H; Becker, R C; Hasselblad, V; Zillman, L A; Kleiman, N S; Hochman, J S; Berger, P B; Cohen, E A; Lincoff, A M; Saint-Jacques, H; Chetcuti, S; Burton, J R; Buergler, J M; Spence, F P; Shimoto, Y; Robertson, T L; Kunitada, S; Bovill, E G; Armstrong, P W; Harrington, R A
2004 Feb;2(2):234-241, Journal of thrombosis & haemostasis : JTH
BACKGROUND: Direct factor (F)Xa inhibition is an attractive method to limit thrombotic complications during percutaneous coronary intervention (PCI). OBJECTIVES: To investigate drug levels achieved, effect on coagulation markers, and preliminary efficacy and safety of several doses of DX-9065a, an intravenous, small molecule, direct, reversible FXa inhibitor during PCI. PATIENTS AND METHODS: Patients undergoing elective, native-vessel PCI (n = 175) were randomized 4 : 1 to open-label DX-9065a or heparin in one of four sequential stages. DX-9065a regimens in stages I-III were designed to achieve concentrations of > 100 ng mL-1, > 75 ng mL-1, and > 150 ng mL-1. Stage IV used the stage III regimen but included patients recently given heparin. RESULTS: At 15 min median (minimum) DX-9065a plasma levels were 192 (176), 122 (117), 334 (221), and 429 (231) ng mL-1 in stages I-IV, respectively. Median whole-blood international normalized ratios (INRs) were 2.6 (interquartile range 2.5, 2.7), 1.9 (1.8, 2.0), 3.2 (3.0, 4.1), and 3.8 (3.4, 4.6), and anti-FXa levels were 0.36 (0.32, 0.38), 0.33 (0.26, 0.39), 0.45 (0.41, 0.51), and 0.62 (0.52, 0.65) U mL-1, respectively. Stage II enrollment was stopped (n = 7) after one serious thrombotic event. Ischemic and bleeding events were rare and, in this small population, showed no clear relation to DX-9065a dose. CONCLUSIONS: Elective PCI is feasible using a direct FXa inhibitor for anticoagulation. Predictable plasma drug levels can be rapidly obtained with double-bolus and infusion DX-9065a dosing. Monitoring of DX-9065a may be possible using whole-blood INR. Direct FXa inhibition is a novel and potentially promising approach to anticoagulation during PCI that deserves further study
— id: 43522, year: 2004, vol: 2, page: 234, stat: Journal Article,

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction)
Antman EM; Anbe DT; Armstrong PW; Bates ER; Green LA; Hand M; Hochman JS; Krumholz HM; Kushner FG; Lamas GA; Mullany CJ; Ornato JP; Pearle DL; Sloan MA; Smith SC Jr; Alpert JS; Anderson JL; Faxon DP; Fuster V; Gibbons RJ; Gregoratos G; Halperin JL; Hiratzka LF; Hunt SA; Jacobs AK; Ornato JP
2004 Aug 4;44(3):E1-E211, Journal of the American College of Cardiology
— id: 72013, year: 2004, vol: 44, page: E1, stat: Journal Article,

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction)
Antman, Elliott M; Anbe, Daniel T; Armstrong, Paul Wayne; Bates, Eric R; Green, Lee A; Hand, Mary; Hochman, Judith S; Krumholz, Harlan M; Kushner, Frederick G; Lamas, Gervasio A; Mullany, Charles J; Ornato, Joseph P; Pearle, David L; Sloan, Michael A; Smith, Sidney C Jr
2004 Aug 4;44(3):671-719, Journal of the American College of Cardiology
— id: 72014, year: 2004, vol: 44, page: 671, stat: Journal Article,

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)
Antman, Elliott M; Anbe, Daniel T; Armstrong, Paul Wayne; Bates, Eric R; Green, Lee A; Hand, Mary; Hochman, Judith S; Krumholz, Harlan M; Kushner, Frederick G; Lamas, Gervasio A; Mullany, Charles J; Ornato, Joseph P; Pearle, David L; Sloan, Michael A; Smith, Sidney C Jr
2004 Aug;20(10):977-1025, Canadian journal of cardiology
— id: 72016, year: 2004, vol: 20, page: 977, stat: Journal Article,

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)
Antman, Elliott M; Anbe, Daniel T; Armstrong, Paul Wayne; Bates, Eric R; Green, Lee A; Hand, Mary; Hochman, Judith S; Krumholz, Harlan M; Kushner, Frederick G; Lamas, Gervasio A; Mullany, Charles J; Ornato, Joseph P; Pearle, David L; Sloan, Michael A; Smith, Sidney C Jr; Alpert, Joseph S; Anderson, Jeffrey L; Faxon, David P; Fuster, Valentin; Gibbons, Raymond J; Gregoratos, Gabriel; Halperin, Jonathan L; Hiratzka, Loren F; Hunt, Sharon Ann; Jacobs, Alice K
2004 Aug 3;110(5):588-636, Circulation
— id: 72018, year: 2004, vol: 110, page: 588, stat: Journal Article,

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)
Antman, Elliott M; Anbe, Daniel T; Armstrong, Paul Wayne; Bates, Eric R; Green, Lee A; Hand, Mary; Hochman, Judith S; Krumholz, Harlan M; Kushner, Frederick G; Lamas, Gervasio A; Mullany, Charles J; Ornato, Joseph P; Pearle, David L; Sloan, Michael A; Smith, Sidney C Jr; Alpert, Joseph S; Anderson, Jeffrey L; Faxon, David P; Fuster, Valentin; Gibbons, Raymond J; Gregoratos, Gabriel; Halperin, Jonathan L; Hiratzka, Loren F; Hunt, Sharon Ann; Jacobs, Alice K
2004 Aug 31;110(9):e82-292, Circulation
— id: 72015, year: 2004, vol: 110, page: e82, stat: Journal Article,

Revascularization outcomes in patients with cardiogenic shock complicating acute myocardial infarction: Observations from the national registry of myocardial infarction
Babaev, A; Frederick, P; Hochman, JS
2004 OCT 26 ;110(17):411-411, Circulation
— id: 55942, year: 2004, vol: 110, page: 411, stat: Journal Article,

Trends in fibrinolytic therapy and intra-aortic balloon pump counterpulsation utilization in patients with cardiogenic shock complicating acute myocardial infarction in hospitals without percutaneous transluminal coronary angioplasty/coronary artery bypass graft capability: Observations from the National Registry of Myocardial Infarction
Babaev, AA; Frederick, PD; Cotiga, D; Hochman, JS
2004 MAR 3 ;43(5):21A-22A, Journal of the American College of Cardiology
— id: 42551, year: 2004, vol: 43, page: 21A, stat: Journal Article,

Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative
Bhatt, Deepak L; Roe, Matthew T; Peterson, Eric D; Li, Yun; Chen, Anita Y; Harrington, Robert A; Greenbaum, Adam B; Berger, Peter B; Cannon, Christopher P; Cohen, David J; Gibson, C Michael; Saucedo, Jorge F; Kleiman, Neal S; Hochman, Judith S; Boden, William E; Brindis, Ralph G; Peacock, W Frank; Smith, Sidney C Jr; Pollack, Charles V Jr; Gibler, W Brian; Ohman, E Magnus
2004 Nov 3;292(17):2096-2104, JAMA
CONTEXT: The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management for high-risk patients, given the benefits with this approach demonstrated in randomized clinical trials. OBJECTIVES: To determine the use and predictors of early invasive management strategies (cardiac catheterization <48 hours following presentation) in high-risk patients with NSTE ACS and to examine the association of early invasive management with mortality. DESIGN, SETTING, AND PATIENTS: The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative evaluated care patterns and outcomes for 17,926 high-risk NSTE ACS patients (positive cardiac markers and/or ischemic electrocardiographic changes) based on ACC/AHA guidelines recommendations at 248 US hospitals with catheterization and revascularization facilities between March 2000 and September 2002. MAIN OUTCOME MEASURES: Use of early invasive management within 48 hours of presentation, predictors of early invasive management, and in-hospital mortality. Results Of the 17,926 patients analyzed, 8037 (44.8%) underwent early cardiac catheterization less than 48 hours following presentation. Predictors of early invasive management included cardiology care, younger age, lack of prior or current congestive heart failure, lack of renal insufficiency, ischemic electrocardiographic changes, positive cardiac markers, white race, and male sex. Patients treated with early invasive management were more likely to be treated with medications and interventions recommended by the ACC/AHA guidelines and had a lower risk of in-hospital mortality after adjusting for differences in clinical characteristics and after comparing propensity-matched pairs (2.5% vs 3.7%, P<.001). Conclusions An early invasive management strategy is not utilized in the majority of high-risk patients with NSTE ACS. This strategy appears to be reserved for patients without significant comorbidities and those cared for by cardiologists and is associated with a lower risk of in-hospital mortality
— id: 72011, year: 2004, vol: 292, page: 2096, stat: Journal Article,

Acute ST-segment elevation myocardial infarction and prior stroke: an analysis from the Magnesium in Coronaries (MAGIC) trial
Cooper, Howard A; Domanski, Michael J; Rosenberg, Yves; Norman, James; Scott, Judith H; Assmann, Susan F; McKinlay, Sonja M; Hochman, Judith S; Antman, Elliott M
2004 Dec;148(6):1012-1019, American heart journal
BACKGROUND: Patients with prior stroke represent a substantial proportion of patients presenting with acute ST-segment elevation myocardial infarction (STEMI). However, the impact of prior stroke on prognosis has not been rigorously examined in the reperfusion era. METHODS: The baseline characteristics, treatments, and clinical outcomes of patients with prior stroke enrolled in the Magnesium in Coronaries (MAGIC) trial were evaluated and compared to those of patients without prior stroke. RESULTS: MAGIC enrolled 6213 patients with STEMI, of whom 558 (9.0%) had prior stroke. Patients with prior stroke were more likely to have a history of hypertension (88.0% vs 70.3%), diabetes (19.9% vs 14.5%), myocardial infarction (38.2% vs 25.1%), and congestive heart failure (15.6% vs 9.7%). The mean Thrombolysis in Myocardial Infarction Risk Score was higher in patients with prior stroke compared to those without prior stroke (4.37 vs 3.93, P < .0001). Patients with prior stroke were less likely to receive reperfusion therapy, even among those considered eligible at presentation (66.3% vs 80.6%, P < .0001). Compared to patients without prior stroke, inhospital stroke (3.0% vs 1.0%, P < .0001), severe congestive heart failure (23.3% vs 18.2%, P = .003), and 30-day mortality (21.0% vs 14.7%, P < .0001) were higher among patients with prior stroke. On multivariable analysis, prior stroke was independently associated with a significantly higher risk of death at 30 days (odds ratio 1.44, P = .0023). CONCLUSIONS: Patients with prior stroke who present with STEMI are at very high risk for short-term morbidity and mortality. Aggressive treatment of these patients appears warranted
— id: 72009, year: 2004, vol: 148, page: 1012, stat: Journal Article,

High rates of persistent cardiogenic shock post-PCI despite reestablishing patency of the infarct-related artery: A report from the SHOCK-2 study group
Farkouh, ME; Ramanathan, K; Buller, CE; Nguyen, CM; Bell, M; Kober, L; Webb, JG; Parrillo, JE; Vered, Z; Harofeh, A; Kleiman, NS; Hochman, JS
2004 OCT 26 ;110(17):449-449, Circulation
— id: 55945, year: 2004, vol: 110, page: 449, stat: Journal Article,

Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial
Ferguson, James J; Califf, Robert M; Antman, Elliott M; Cohen, Marc; Grines, Cindy L; Goodman, Shaun; Kereiakes, Dean J; Langer, Anatoly; Mahaffey, Kenneth W; Nessel, Christopher C; Armstrong, Paul W; Avezum, Alvaro; Aylward, Phil; Becker, Richard C; Biasucci, Luigi; Borzak, Steven; Col, Jacques; Frey, Marty J; Fry, Ed; Gulba, Dietrich C; Guneri, Sema; Gurfinkel, Enrique; Harrington, Robert; Hochman, Judith S; Kleiman, Neal S; Leon, Martin B; Lopez-Sendon, Jose Luis; Pepine, Carl J; Ruzyllo, Witold; Steinhubl, Steven R; Teirstein, Paul S; Toro-Figueroa, Luis; White, Harvey
2004 Jul 7;292(1):45-54, JAMA
CONTEXT: Enoxaparin has demonstrated advantages over unfractionated heparin in low- to moderate-risk patients with non-ST-segment elevation acute coronary syndromes (ACS) treated with a conservative strategy. OBJECTIVES: To compare the outcomes of patients treated with enoxaparin vs unfractionated heparin and to define the role of enoxaparin in patients with non-ST-segment elevation ACS at high risk for ischemic cardiac complications managed with an early invasive approach. DESIGN, SETTING, AND PARTICIPANTS: The Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial was a prospective, randomized, open-label, multicenter, international trial conducted between August 2001 and December 2003. A total of 10 027 high-risk patients with non-ST-segment elevation ACS to be treated with an intended early invasive strategy were recruited. INTERVENTIONS: Subcutaneous enoxaparin (n = 4993) or intravenous unfractionated heparin (n = 4985) was to be administered immediately after enrollment and continued until the patient required no further anticoagulation, as judged by the treating physician. MAIN OUTCOME MEASURES: The primary efficacy outcome was the composite clinical end point of all-cause death or nonfatal myocardial infarction during the first 30 days after randomization. The primary safety outcome was major bleeding or stroke. RESULTS: The primary end point occurred in 14.0% (696/4993) of patients assigned to enoxaparin and 14.5% (722/4985) of patients assigned to unfractionated heparin (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.86-1.06). No differences in ischemic events during percutaneous coronary intervention (PCI) were observed between enoxaparin and unfractionated heparin groups, respectively, including similar rates of abrupt closure (31/2321 [1.3%] vs 40/2364 [1.7%]), threatened abrupt closure (25/2321 [1.1%] vs 24/2363 [1.0%]), unsuccessful PCI (81/2281 [3.6%] vs 79/2328 [3.4%]), or emergency coronary artery bypass graft surgery (6/2323 [0.3%] vs 8/2363 [0.3%]). More bleeding was observed with enoxaparin, with a statistically significant increase in TIMI (Thrombolysis in Myocardial Infarction) major bleeding (9.1% vs 7.6%, P =.008) but nonsignificant excess in GUSTO (Global Utilization of Streptokinase and t-PA for Occluded Arteries) severe bleeding (2.7% vs 2.2%, P =.08) and transfusions (17.0% vs 16.0%, P =.16). CONCLUSIONS: Enoxaparin was not superior to unfractionated heparin but was noninferior for the treatment of high-risk patients with non-ST-segment elevation ACS. Enoxaparin is a safe and effective alternative to unfractionated heparin and the advantages of convenience should be balanced with the modest excess of major bleeding
— id: 43521, year: 2004, vol: 292, page: 45, stat: Journal Article,

Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry
Fincke, Rupert; Hochman, Judith S; Lowe, April M; Menon, Venu; Slater, James N; Webb, John G; LeJemtel, Thierry H; Cotter, Gad
2004 Jul 21;44(2):340-348, Journal of the American College of Cardiology
OBJECTIVES: We sought to analyze clinical, angiographic, and outcome correlates of hemodynamic parameters in cardiogenic shock. BACKGROUND: The significance of right heart catheterization in critically ill patients is controversial, despite the prognostic importance of the derived measurements. Cardiac power is a novel hemodynamic parameter. METHODS: A total of 541 patients with cardiogenic shock who were enrolled in the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial registry were included. Cardiac power output (CPO) (W) was calculated as mean arterial pressure x cardiac output/451. RESULTS: On univariate analysis, CPO, cardiac power index (CPI), cardiac output, cardiac index, stroke volume, left ventricular work, left ventricular work index, stroke work, mean arterial pressure, systolic and diastolic blood pressure (all p < 0.001), coronary perfusion pressure (p = 0.002), ejection fraction (p = 0.013), and pulmonary artery systolic pressure (p = 0.047) were associated with in-hospital mortality. In separate multivariate analyses, CPO (odds ratio per 0.20 W: 0.60 [95% confidence interval, 0.44 to 0.83], p = 0.002; n = 181) and CPI (odds ratio per 0.10 W/m(2): 0.65 [95% confidence interval, 0.48 to 0.87], p = 0.004; n = 178) remained the strongest independent hemodynamic correlates of in-hospital mortality after adjusting for age and history of hypertension. There was an inverse correlation between CPI and age (correlation coefficient: -0.334, p < 0.001). Women had a lower CPI than men (0.29 +/- 0.11 vs. 0.35 +/- 0.15 W/m(2), p = 0.005). After adjusting for age, female gender remained associated with CPI (p = 0.032). CONCLUSIONS: Cardiac power is the strongest independent hemodynamic correlate of in-hospital mortality in patients with cardiogenic shock. Increasing age and female gender are independently associated with lower cardiac power
— id: 43520, year: 2004, vol: 44, page: 340, stat: Journal Article,

Why did the anti-C5 complement antibody pexelizumab not reduce infarct size but influence clinical outcomes positively when applied as adjunctive therapy to primary percutaneous coronary intervention? Response
Granger, CB; Mahaffey, KW; Weaver, WD; Theroux, P; Hochman, JS; Filloon, TG; Todaro, TG; Rollins, S; Mojcik, CF; Nicolau, JC; Ruzyllo, W; Armstrong, PW
2004 APR 27 ;109(16):E195-E196, Circulation
— id: 46645, year: 2004, vol: 109, page: E195, stat: Journal Article,

Causes of death in cardiogenic shock - A report from the SHOCK trial
Jager, RV; Assmann, SF; Yehudai, L; Tita, C; Ramanathan, K; Farkouh, ME; Hochman, JS
2004 OCT 26 ;110(17):411-411, Circulation
— id: 55943, year: 2004, vol: 110, page: 411, stat: Journal Article,

Feasibility of endovascular cooling as an adjunct to primary percutaneous coronary intervention (results of the LOWTEMP pilot study)
Kandzari, David E; Chu, Alan; Brodie, Bruce R; Stuckey, Thomas A; Hermiller, James B; Vetrovec, George W; Hannan, Karen L; Krucoff, Mitchell W; Christenson, Robert H; Gibbons, Raymond J; Sigmon, Kristina N; Garg, Jyostna; Hasselblad, Victor; Collins, Kenneth; Harrington, Robert A; Berger, Peter B; Chronos, Nicholas A; Hochman, Judith S; Califf, Robert M
2004 Mar 1;93(5):636-639, American journal of cardiology
In a nonrandomized feasibility study of therapeutic hypothermia in acute myocardial infarction, 18 patients were treated with endovascular cooling (Alsius, Irvine, California) as adjunctive therapy to primary percutaneous coronary intervention to assess measures of infarct size (area under the curve creatinine kinase-MB and technetium-99m single-photon emission computed tomography sestamibi) and the quality of myocardial perfusion (continuous ST-segment monitoring). Periprocedural endovascular cooling successfully decreased core body temperature (median 33.5 degrees C) and was well tolerated, which supports the evaluation of adjunctive hypothermia in pivotal trials to limit infarct size and decrease reperfusion injury
— id: 43523, year: 2004, vol: 93, page: 636, stat: Journal Article,

Establishing a new target range for unfractionated heparin for acute coronary syndromes
Lee, Michael S; Menon, Venu; Schappert, Joseph; Wilentz, James R; Singh, Varinder; Hochman, Judith S
2004 Apr;17(2):121-126, Journal of thrombosis & thrombolysis
INTRODUCTION: The target activated partial thromboplastin time (aPTT) range of 1.5 to 2.5 times the control value or 45 to 75 seconds recommended by the ACC/AHA for patients receiving unfractionated heparin (UFH) for acute coronary syndromes (ACS) is vulnerable to variation in test reagents. Rather than use the standard target aPTT range, it has been recommended that each institution establish its own target aPTT range based upon anti-factor Xa heparin levels. As a quality assurance project, we evaluated our institution's therapeutic aPTT range by examining the correlation between aPTTs and anti-factor Xa heparin levels and established a new target aPTT range with a new thromboplastin reagent based upon the therapeutic anti-factor Xa heparin levels. METHODS: Sixty-two plasma samples from 26 consecutive patients receiving UFH for ACS were analyzed. Plasma aPTTs measured with a thromboplastin reagent and a new thromboplastin reagent and anti-factor Xa heparin levels were obtained on each plasma sample. Linear regression analysis was performed to establish a new target aPTT range from corresponding therapeutic anti-factor Xa heparin levels. RESULTS: Thirty-two percent of patients with our institution's target range aPTTs of 61 to 100 seconds had anti-factor Xa heparin levels below 0.35 to 0.7 U/mL while 68% of patients had therapeutic anti-factor Xa heparin levels (positive predictive value = 68%). When the same blood was tested with a new thromboplastin reagent lot, only 9% of patients with target range aPTTs had anti-factor Xa heparin levels below 0.35 U/mL while 91% of patients had therapeutic anti-factor Xa heparin levels (positive predictive value = 91%). The Pearson correlation coefficient ( r ) for the new thromboplastin reagent lot was 0.93. The target aPTT range established with the new thromboplastin reagent lot was 61 to 100 seconds. CONCLUSION: Monitoring aPTTs without standardizing the thromboplastin reagent may not adequately reflect therapeutic heparin levels. Despite apparently target aPTTs, patients treated with UFH may be under-anticoagulated. Our new anti-Xa-adjusted target aPTT range shows an increase in the positive predictive value of aPTTs. Large-scale clinical studies are needed to determine the optimal anti-factor Xa range for ACS patients treated with UFH, with further refinements if glycoprotein IIb/IIIa inhibitors are concomitantly used and to show a benefit in clinical outcomes for monitoring plasma heparin levels with anti-factor Xa heparin levels. Institutional standardization of the aPTT is necessary to ensure optimal patient care when changing thromboplastin reagents
— id: 72017, year: 2004, vol: 17, page: 121, stat: Journal Article,

Association of diabetes mellitus and glycemic control strategies with clinical outcomes after acute coronary syndromes
McGuire, Darren K; Newby, L Kristin; Bhapkar, Manjushri V; Moliterno, David J; Hochman, Judith S; Klein, Werner W; Weaver, W Douglas; Pfisterer, Matthias; Corbalan, Ramon; Dellborg, Mikael; Granger, Christopher B; Van De Werf, Frans; Topol, Eric J; Califf, Robert M
2004 Feb;147(2):246-252, American heart journal
BACKGROUND: Diabetes is associated with an increased risk for coronary artery disease (CAD) and its complications. The relative effect of glucose-lowering strategies of 'insulin provision' versus 'insulin sensitization' among patients with CAD remains unclear. METHODS: To evaluate the associations of diabetes and hypoglycemic strategies with clinical outcomes after acute coronary syndromes, we analyzed data from 15,800 patients enrolled in the SYMPHONY and 2nd SYMPHONY trials. RESULTS: Compared with nondiabetic patients, patients with diabetes (n = 3101; 19.6%) were older, more often female, more often had prior CAD, hypertension, and hyperlipidemia, and less often were current smokers. The diabetic cohort had higher 90-day unadjusted risk of the composite of death/myocardial infarction (MI)/severe recurrent ischemia (SRI), death/MI, and death alone, as well as a near doubling of 1-year mortality rates. At 1 year, diabetes was associated with significantly higher adjusted risks of death/MI/SRI (OR, 1.3 [95% confidence interval, 1.1, 1.5]) and death/MI (OR, 1.2 [1.0, 1.4]). Hypoglycemic therapy including only insulin and/or sulfonylurea (insulin-providing; n = 1473) was associated with higher 90-day death/MI/SRI compared with therapy that included only biguanide and/or thiazolidinedione therapy (insulin-sensitizing; n = 100) (12.0% vs 5.0%); (adjusted OR, 2.1 [1.2, 3.7]). CONCLUSIONS: Diabetic patients with acute coronary syndromes had worse clinical outcomes. Although the findings regarding the influence of glycemic-control strategies should be interpreted with caution because of the exploratory nature of the analyses and the relatively small sample size of the insulin-sensitizing group, the improved risk-adjusted outcomes associated with insulin-sensitizing therapy underscore the need to further evaluate treatment strategies for patients with diabetes and CAD
— id: 43524, year: 2004, vol: 147, page: 246, stat: Journal Article,

Thrombolysis and adjunctive therapy in acute myocardial infarction: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Menon, Venu; Harrington, Robert A; Hochman, Judith S; Cannon, Christopher P; Goodman, Shaun D; Wilcox, Robert G; Schunemann, Holger J; Ohman, E Magnus
2004 Sep;126(3 Suppl):549S-575S, Chest
This chapter about antithrombotic therapy for acute myocardial infarction (MI) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with ischemic symptoms characteristic of acute MI of < 12 h in duration, and ST-segment elevation or left bundle-branch block (of unknown duration) on the ECG, we recommend administration of any approved fibrinolytic agent (Grade 1A). We recommend the use of streptokinase, anistreplase, alteplase, reteplase, or tenecteplase over placebo (all Grade 1A). For patients with symptom duration < 6 h, we recommend the administration of alteplase over streptokinase (Grade 1A). For patients with known allergy or sensitivity to streptokinase, we recommend alteplase, reteplase, or tenecteplase (Grade 1A). For patients with acute posterior MI of < 12 h duration, we suggest fibrinolytic therapy (Grade 2C). In patients with any history of intracranial hemorrhage, closed head trauma, or ischemic stroke within past 3 months, we recommend against administration of fibrinolytic therapy (Grade 1C+). For patients with acute ST-segment elevation MI whether or not they receive fibrinolytic therapy, we recommend aspirin, 160 to 325 mg p.o., at initial evaluation by health-care personnel followed by indefinite therapy, 75 to 162 mg/d p.o. (both Grade 1A). In patients allergic to aspirin, we suggest use of clopidogrel as an alternative therapy to aspirin (Grade 2C). For patients receiving streptokinase, we suggest administration of either i.v. unfractionated heparin (UFH) [Grade 2C] or subcutaneous UFH (Grade 2A). For all patients at high risk of systemic or venous thromboembolism (anterior MI, pump failure, previous embolus, atrial fibrillation, or left ventricular thrombus), we recommend administration of IV UFH while receiving streptokinase (Grade 1C+)
— id: 72012, year: 2004, vol: 126, page: 549S, stat: Journal Article,

Cardiogenic shock in patients with preserved left ventricular systolic function: Characteristics and insight into mechanisms
Ramanathan, K; Harkness, SM; Nayar, AC; Cosmi, JE; Sleeper, LS; White, HD; Davidoff, R; Hochman, JS
2004 MAR 3 ;43(5):241A-241A, Journal of the American College of Cardiology
— id: 42449, year: 2004, vol: 43, page: 241A, stat: Journal Article,

Long-term survivors of cardiogenic shock enjoy good functional capacity, and a strategy of early revascularization is protective against functional class deterioration and death
Ramanathan, K; Sleeper, LA; Picard, MH; White, HD; LeJemtel, TH; Dzavik, V; Tormey, D; Avis, NE; Hochman, JS
2004 MAR 3 ;43(5):275A-275A, Journal of the American College of Cardiology
— id: 42451, year: 2004, vol: 43, page: 275A, stat: Journal Article,

Female sex: A more important prognostic marker than treatment assignment or comorbid conditions among patients with acute myocardial infarction in the GUSTO V Trial
Reynolds, HR; Farkouh, ME; Swahn, E; White, JA; Sadowski, ZP; Lincoff, AM; Topol, EJ; Hochman, JS
2004 MAR 3 ;43(5):261A-261A, Journal of the American College of Cardiology
— id: 42450, year: 2004, vol: 43, page: 261A, stat: Journal Article,

LV geometry and mitral regurgitation in patients with persistent total occlusion of the infarct artery in OAT
Reynolds, HR; Ramanathan, K; Lamas, GA; Forman, S; Anagnostopoulos, CE; Rankin, JM; Carere, RG; Hochman, JS; Buller, CE
2004 OCT 26 ;110(17):659-659, Circulation
— id: 55947, year: 2004, vol: 110, page: 659, stat: Journal Article,

Evaluating the benefits of glycoprotein IIb/IIIa inhibitors in heart failure at baseline in acute coronary syndromes
Srichai, Monvadi B; Jaber, Wael A; Prior, David L; Marso, Steven P; Houghtaling, Penny L; Menon, Venu; Simoons, Maarten L; Harrington, Robert A; Hochman, Judith S
2004 Jan;147(1):84-90, American heart journal
BACKGROUND: We evaluated whether the use of glycoprotein IIb/IIIa receptor inhibitors, in addition to heparin and aspirin, imparts an incremental benefit in a subgroup of patients with acute coronary syndromes (ACS) who had congestive heart failure (CHF) symptoms at presentation. METHODS: We analyzed patients enrolled in the Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, a randomized, double-blind, placebo-controlled study evaluating the use of eptifibatide versus placebo for patients with ACS without persistent ST-elevation. We compared the clinical characteristics and 30-day outcomes for 861 patients who had Killip class II or III CHF symptoms with those of 8558 patients who had no CHF symptoms. RESULTS: Odds ratios for the primary end point, 30-day death or non-fatal myocardial infarction, in the placebo group versus the eptifibatide group were similar for patients with and without CHF (odds ratio, 1.11; 95% CI, 0.8-1.5; odds ratio, 1.13; 95% CI, 1.0-1.3). However, adverse events were almost twice as frequent for patients with CHF compared with patients with no CHF (24.5% vs 14%). CONCLUSIONS: Although patients with non-ST-segment elevation ACS who have CHF have markedly worse outcomes than patients without CHF symptoms, we did not find an incremental benefit from the use of eptifibatide in this seriously ill subgroup
— id: 43526, year: 2004, vol: 147, page: 84, stat: Journal Article,

Benefits of direct angioplasty for women and men with acute myocardial infarction: results of the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B) Angioplasty Substudy
Tamis-Holland, Jacqueline E; Palazzo, Angela; Stebbins, Amanda L; Slater, James N; Boland, Jean; Ellis, Stephen G; Hochman, Judith S
2004 Jan;147(1):133-139, American heart journal
BACKGROUND: Direct angioplasty (PTCA) and thrombolytic therapy are the chief therapies for treating an ST-segment elevation myocardial infarction (MI). OBJECTIVE: This study was designed to evaluate sex differences in the relative benefit of direct PTCA versus thrombolytic therapy among patients enrolled in the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B PTCA) Substudy. METHODS: Women and men presenting with an acute ST-segment elevation MI were randomized to receive either direct PTCA or accelerated tissue plasminogen activator (t-PA). Patients were then randomized to treatment with either heparin or bivalirudin. A gender analysis of outcome was performed. RESULTS: Women were older than men (68.6 +/- 11.5 vs 59.5 +/- 12.0 years, P <.001) and were more likely to have diabetes (22.5% vs 13.5%, P <.0001) and hypertension (53.3% vs 34.8%, P =.001). After adjusting for differences in baseline variables, the odds ratio (OR) for reaching a 30-day clinical end point (death, nonfatal infarction, or nonfatal disabling stroke) was similar for women and men (1.35, 95% CI 0.88-2.08). The OR for reaching a clinical end point at 30 days for the PTCA-treated women compared with the t-PA-treated women was 0.685 (95% CI 0.36-1.32) and similar to the OR in men, 0.565 (95% CI 0.35-0.91), P for interaction =.535. Because women had a higher event rate than men, the absolute number of major events prevented when treating women with direct PTCA was higher than men (56 events/1000 women treated with PTCA vs 42 events per 1000 men treated with PTCA). CONCLUSIONS: Although the relative benefit of direct PTCA to t-PA for the treatment of an acute MI appears to be similar in women and men, women may derive a larger absolute benefit from direct PTCA
— id: 43525, year: 2004, vol: 147, page: 133, stat: Journal Article,

Congestive heart failure and cardiogenic shock complicating acute myocardial infarction have high mortality and are associated with intense inflammatory response: Results from the CARDINAL trials
Valencia, R; Theroux, P; Granger, CB; Mahaffey, KW; Gudaye, T; Malloy, K; Weaver, WD; Todaro, TG; Mojcik, CF; Armstrong, PW; Hochman, JS
2004 MAR 3 ;43(5):291A-291A, Journal of the American College of Cardiology
— id: 42553, year: 2004, vol: 43, page: 291A, stat: Journal Article,

Electrocardiographic findings in cardiogenic shock, risk prediction, and the effects of emergency revascularization: results from the SHOCK trial
White, Harvey D; Palmeri, Sebastian T; Sleeper, Lynn A; French, John K; Wong, Cheuk-Kit; Lowe, April M; Crapo, Julia W; Koller, Patrick T; Baran, Kenneth W; Boland, Jean L; Hochman, Judith S; Wagner, Galen S
2004 Nov;148(5):810-817, American heart journal
OBJECTIVES: To evaluate electrocardiographic (ECG) parameters as predictors of 1-year mortality in patients developing cardiogenic shock after acute myocardial infarction (AMI), and to document associations between these ECG parameters and the survival benefit of emergency revascularization versus initial medical stabilization. BACKGROUND: Emergency revascularization reduces the risk of mortality in patients developing cardiogenic shock after AMI. The prognostic value of ECG parameters in such patients is unclear, and it is uncertain whether emergency revascularization reduces the mortality risk denoted by ECG parameters. METHODS: In a prospective substudy of 198 SHOCK (SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK) trial patients, ECGs recorded within 12 hours of shock were interpreted by personnel blinded to the patients' treatment assignment and outcome. RESULTS: The baseline heart rate was higher in non-survivors than in survivors (106 +/- 20 versus 95 +/- 24 beats/minute, P = .001). There was a significant association between the QRS duration and 1-year mortality in medically stabilized patients (115 +/- 28 ms in non-survivors versus 99 +/- 23 ms in survivors, P = .012), but not in emergently revascularized patients (110 +/- 31 versus 116 +/- 27 ms respectively, P = .343). The interaction between the QRS duration, mortality and treatment assignment was significant (P = .009). Among patients with inferior AMI, a greater sum of ST depression was associated with higher 1-year mortality in medically stabilized patients (P = .029), but not in emergently revascularized patients (P = .613, treatment interaction P = .025). On multivariate analysis, the independent mortality predictors were increasing age, elevated pulmonary capillary wedge pressure, heart rate, sum of ST depression in medically stabilized patients, and interaction (P = .016) between a prolonged QRS duration and treatment assignment. The adjusted hazard ratio for 1-year mortality per 20 ms increase in the QRS duration was 1.19 (95% CI 0.98-1.46) in medically stabilized patients and 0.81 (95% CI 0.63-1.03) in emergently revascularized patients. CONCLUSION: ECG parameters identified patients with cardiogenic shock who were at high risk. Emergency revascularization eliminated the incremental mortality risk associated with cardiogenic shock in patients with a prolonged QRS duration, or inferior AMI accompanied by precordial ST depression. Prospective assessments of the magnitude of the treatment effect based on ECG parameters are required
— id: 72010, year: 2004, vol: 148, page: 810, stat: Journal Article,

Relation between hospital intra-aortic balloon counterpulsation volume and mortality in acute myocardial infarction complicated by cardiogenic shock
Chen, Edmond W; Canto, John G; Parsons, Lori S; Peterson, Eric D; Littrell, Katherine A; Every, Nathan R; Gibson, C Michael; Hochman, Judith S; Ohman, E Magnus; Cheeks, Morris; Barron, Hal V
2003 Aug 26;108(8):951-957, Circulation
BACKGROUND: Increasing evidence suggests an inverse relationship between outcome and the total number of invasive cardiac procedures performed at a given hospital. The purpose of the present study was to determine if a similar relationship exists between the number of intra-aortic balloon counterpulsation (IABP) procedures performed at a given hospital per year and the in-hospital mortality rate of patients with acute myocardial infarction complicated by cardiogenic shock. METHODS AND RESULTS: We analyzed data of 12 730 patients at 750 hospitals enrolled in the National Registry of Myocardial Infarction 2 from 1994 to 1998. The hospitals were divided into tertiles (low-, intermediate-, and high-IABP volume hospitals) according to the number of IABPs performed at the given hospital per year. The median number of IABPs performed per hospital per year was 3.4, 12.7, and 37.4 IABPs at low-, intermediate-, and high-volume hospitals, respectively. Of those patients who underwent IABP, there were only minor differences in baseline patient characteristics between the 3 groups. Crude mortality rate decreased with increasing IABP volume: 65.4%, lowest volume tertile; 54.1%, intermediate volume tertile; and 50.6%, highest volume tertile (P for trend <0.001). This mortality difference represented 150 fewer deaths per 1000 patients treated at the high IABP hospitals. In the multivariate analysis, high hospital IABP volume for patients with acute myocardial infarction was associated with lower mortality (OR=0.71, 95% CI=0.56 to 0.90), independent of baseline patient characteristics, hospital factors, treatment, and procedures such as PTCA. CONCLUSIONS: Among the myocardial infarction patients with cardiogenic shock who underwent IABP placement, mortality rate was significantly lower at high-IABP volume hospitals compared with low-IABP volume hospitals
— id: 38905, year: 2003, vol: 108, page: 951, stat: Journal Article,

Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry
Dzavik, V; Sleeper, L A; Cocke, T P; Moscucci, M; Saucedo, J; Hosat, S; Jiang, X; Slater, J; LeJemtel, T; Hochman, J S
2003 May;24(9):828-837, European heart journal
AIMS: The SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK (SHOCK) Trial showed no benefit of early revascularization in patients aged >/=75 years with acute myocardial infarction and cardiogenic shock. We examined the effect of age on treatment and outcomes of patients with cardiogenic shock in the SHOCK Trial Registry. METHODS AND RESULTS: We compared clinical and treatment factors in patients in the SHOCK Trial Registry with shock due to pump failure aged <75 years (n=588) and >/=75 years (n=277), and 30-day mortality of patients treated with early revascularization <18 hours since onset of shock and those undergoing a later or no revascularization procedure. After excluding early deaths covariate-adjusted relative risk and 95% confidence intervals were calculated to compare the revascularization strategies within the two age groups. Older patients more often had prior myocardial infarction, congestive heart failure, renal insufficiency, other comorbidities, and severe coronary anatomy. In-hospital mortality in the early vs. late or no revascularization groups was 45 vs. 61% for patients aged <75 years (p=0.002) and 48 vs. 81% for those aged >/=75 years (p=0.0003). After exclusion of 65 early deaths and covariate adjustment, the relative risk was 0.76 (0.59, 0.99; p=0.045) in patients aged <75 years and 0.46 (0.28, 0.75; p=0.002) in patients aged >/=75 years. CONCLUSIONS: Elderly patients with myocardial infarction complicated by cardiogenic shock are less likely to be treated with invasive therapies than younger patients with shock. Covariate-adjusted modeling reveals that elderly patients selected for early revascularization have a lower mortality rate than those receiving a revascularization procedure later or never
— id: 38907, year: 2003, vol: 24, page: 828, stat: Journal Article,

Influence of thrombolytic therapy, with or without intra-aortic balloon counterpulsation, on 12-month survival in the SHOCK trial
French, John K; Feldman, Henry A; Assmann, Susan F; Sanborn, Timothy; Palmeri, Sebastian T; Miller, David; Boland, Jean; Buller, Christopher E; Steingart, Richard; Sleeper, Lynn A; Hochman, Judith S
2003 Nov;146(5):804-810, American heart journal
BACKGROUND: The enhancement of diastolic coronary blood flow by the combination of thrombolytic therapy (TT) and intra-aortic balloon counterpulsation (IABP) in experimental studies provides a rationale for their combined use in acute myocardial infarction (MI) complicated by cardiogenic shock. We examined the relation between TT (with and without IABP) and 12-month survival in the SHould We Emergently Revascularize Occluded Coronaries for Cardiogenic ShocK (SHOCK) Trial. METHODS AND RESULTS: Among 302 patients with myocardial infarction and cardiogenic shock who were randomized in the SHOCK Trial, 16 had absolute contraindications to TT. Among 150 patients randomly assigned to initial medical stabilization (IMS), 63% received TT, as recommended per protocol, compared with 49% of 152 patients randomly assigned to emergency revascularization, in whom TT was not recommended if immediate angiography was available. IABP deployment, which was protocol-recommended, was used in 86% of patients. The rate of severe bleeding was similar in patients receiving TT and in those not receiving TT (31% vs 26%, P =.37). Among patients randomly assigned to IMS, TT was associated with improved 12-month survival (unadjusted mortality hazard ratio, 0.59; P =.01; mortality hazard ratio adjusted for age and prior MI, 0.62; P =.02). TT was not associated with improved 12-month survival among patients randomly assigned to emergency revascularization (unadjusted mortality hazard ratio, 0.93; P =.76; mortality hazard ratio adjusted for age and prior MI, 1.06, P =.81). The test for interaction of TT and randomization group P value was.16, and there was insufficient statistical power to demonstrate a differential effect of TT on 12-month survival by treatment group assignment. CONCLUSIONS: Among patients randomly assigned to IMS in the SHOCK Trial, TT was associated with improved 12-month survival and did not significantly increase the risk of severe bleeding
— id: 38898, year: 2003, vol: 146, page: 804, stat: Journal Article,

Pexelizumab, an anti-C5 complement antibody, as adjunctive therapy to primary percutaneous coronary intervention in acute myocardial infarction: the COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA) trial
Granger, Christopher B; Mahaffey, Kenneth W; Weaver, W Douglas; Theroux, Pierre; Hochman, Judith S; Filloon, Thomas G; Rollins, Scott; Todaro, Thomas G; Nicolau, Jose C; Ruzyllo, Witold; Armstrong, Paul W
2003 Sep 9;108(10):1184-1190, Circulation
BACKGROUND: Complement, activated during myocardial ischemia and reperfusion, causes myocardial damage through multiple processes. The COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA) trial was performed to determine the effect of pexelizumab, a C5 complement inhibitor, on infarct size in patients with ST-segment-elevation myocardial infarction (MI) undergoing primary percutaneous coronary intervention. METHODS AND RESULTS: In COMMA, 960 patients with MI (20% isolated inferior MI) were randomized to placebo, pexelizumab 2.0-mg/kg bolus, or pexelizumab 2.0-mg/kg bolus and 0.05-mg/kg per h infusion for 20 hours. Infarct size by creatine kinase-MB area under the curve, the primary outcome, did not differ significantly between groups (placebo median, 4393; bolus pexelizumab, 4526; bolus plus infusion pexelizumab, 4713 [ng/mL] x h; P=0.89 for bolus versus placebo; P=0.76 for bolus plus infusion versus placebo), nor did the composite of 90-day death, new or worsening heart failure, shock, or stroke (placebo, 11.1%; bolus, 10.7%; bolus plus infusion, 8.5%). The ninety-day mortality rate was significantly lower with pexelizumab bolus plus infusion (1.8% versus 5.9% with placebo; nominal P=0.014); the bolus-only group had an intermediate mortality rate (4.2%). CONCLUSIONS: In patients with ST-elevation MI undergoing percutaneous coronary intervention, pexelizumab had no measurable effect on infarct size. However, the significant reduction in mortality suggests that pexelizumab may benefit patients through alternative novel mechanisms and provides impetus for additional investigation
— id: 38904, year: 2003, vol: 108, page: 1184, stat: Journal Article,

Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm
Hochman, Judith S
2003 Jun 24;107(24):2998-3002, Circulation
— id: 38906, year: 2003, vol: 107, page: 2998, stat: Journal Article,

Cardiogenic shock caused by right ventricular infarction: a report from the SHOCK registry
Jacobs, Alice K; Leopold, Jane A; Bates, Eric; Mendes, Lisa A; Sleeper, Lynn A; White, Harvey; Davidoff, Ravin; Boland, Jean; Modur, Sharada; Forman, Robert; Hochman, Judith S
2003 Apr 16;41(8):1273-1279, Journal of the American College of Cardiology
OBJECTIVES: The purpose of this study was to determine the characteristics and outcomes of patients with acute myocardial infarction (MI) complicated by cardiogenic shock due to predominant right ventricular (RV) infarction. BACKGROUND: Although RV infarction has been shown to have favorable long-term outcomes, the influence of RV infarction on mortality in cardiogenic shock is unknown. METHODS: We evaluated 933 patients in cardiogenic shock due to predominant RV (n = 49) or left ventricular (LV) failure (n = 884) in the SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK? (SHOCK) trial registry. RESULTS: Patients with predominant RV shock were younger, with a lower prevalence of previous MI (25.5 vs. 40.1%, p = 0.047), anterior MI, and multivessel disease (34.8 vs. 77.8%, p < 0.001) and a shorter median time between the index MI and the diagnosis of shock (2.9 vs. 6.2 h, p = 0.003) in comparison to patients with LV shock. In-hospital mortality was 53.1% versus 60.8% (p = 0.296) for patients with predominant RV and LV shock, respectively, and the influence of revascularization on mortality was not different between groups. Multivariate analysis revealed that RV shock was not an independent predictor of lower in-hospital mortality (odds ratio 1.07, 95% confidence interval 0.54 to 2.13). CONCLUSIONS: Despite the younger age, lower rate of anterior MI, and higher prevalence of single-vessel coronary disease of RV compared with LV shock patients, and their similar benefit from revascularization, mortality is unexpectedly high in patients with predominant RV shock and similar to patients with LV shock
— id: 38909, year: 2003, vol: 41, page: 1273, stat: Journal Article,

Effect of pexelizumab, an anti-C5 complement antibody, as adjunctive therapy to fibrinolysis in acute myocardial infarction: the COMPlement inhibition in myocardial infarction treated with thromboLYtics (COMPLY) trial
Mahaffey, Kenneth W; Granger, Christopher B; Nicolau, Jose C; Ruzyllo, Witold; Weaver, W Douglas; Theroux, Pierre; Hochman, Judith S; Filloon, Thomas G; Mojcik, Christopher F; Todaro, Thomas G; Armstrong, Paul W
2003 Sep 9;108(10):1176-1183, Circulation
BACKGROUND: Complement activation mediates myocardial damage that occurs during ischemia and reperfusion through multiple pathways. We performed 2 separate, parallel, double-blind, placebo-controlled trials to determine the effects of pexelizumab (a novel C5 complement monoclonal antibody fragment) on infarct size in patients receiving reperfusion therapy: COMPlement inhibition in myocardial infarction treated with thromboLYtics (COMPLY) and COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA). The COMPLY trial is reported here. METHODS AND RESULTS: Overall, 943 patients with acute ST-segment elevation myocardial infarction (MI) (20% with isolated inferior MI) receiving fibrinolysis were randomly assigned <6 hours after symptom onset to placebo, pexelizumab 2.0-mg/kg bolus, or pexelizumab 2.0-mg/kg bolus plus 0.05 mg/kg per h for 20 hours. Infarct size determined by creatine kinase-MB area under the curve was the primary analysis, which included patients who received at least some study drug and fibrinolysis (n=920). The median infarct size did not differ by treatment (placebo, 5230; bolus, 4952; bolus plus infusion, 5557 [ng/mL] x h; bolus versus placebo, P=0.85; bolus plus infusion versus placebo, P=0.81), nor did the 90-day composite incidence of death, new or worsening congestive heart failure, shock, or stroke (placebo, 18.6%; bolus, 18.4%; bolus plus infusion, 19.7%). Pexelizumab inhibited complement for 4 hours with bolus-only dosing and for 20 to 24 hours with bolus-plus-infusion dosing, with no increase in infections. CONCLUSIONS: When used adjunctively with fibrinolysis, pexelizumab blocked complement activity but reduced neither infarct size by creatine kinase-MB assessment nor adverse clinical outcomes
— id: 38903, year: 2003, vol: 108, page: 1176, stat: Journal Article,

American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines
Maron, Barry J; McKenna, William J; Danielson, Gordon K; Kappenberger, Lukas J; Kuhn, Horst J; Seidman, Christine E; Shah, Pravin M; Spencer, William H 3rd; Spirito, Paolo; Ten Cate, Folkert J; Wigle, E Douglas
2003 Nov 5;42(9):1687-1713, Journal of the American College of Cardiology
— id: 38897, year: 2003, vol: 42, page: 1687, stat: Journal Article,

American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines
Maron, Barry J; McKenna, William J; Danielson, Gordon K; Kappenberger, Lukas J; Kuhn, Horst J; Seidman, Christine E; Shah, Pravin M; Spencer, William H 3rd; Spirito, Paolo; Ten Cate, Folkert J; Wigle, E Douglas
2003 Nov;24(21):1965-1991, European heart journal
— id: 38899, year: 2003, vol: 24, page: 1965, stat: Journal Article,

Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock
Picard, Michael H; Davidoff, Ravin; Sleeper, Lynn A; Mendes, Lisa A; Thompson, Christopher R; Dzavik, Vladimir; Steingart, Richard; Gin, Ken; White, Harvey D; Hochman, Judith S
2003 Jan 21;107(2):279-284, Circulation
BACKGROUND: Although echocardiography is used in diagnosis and management of myocardial infarction, it has not been established whether specific features of cardiac structure or function early in the course of cardiogenic shock provide prognostic value. The purposes of this substudy of the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial were to describe the echocardiographic features of cardiogenic shock, identify findings on early echocardiograms associated with outcome, examine the interaction of such features with treatment, and determine whether these features could provide insights into the survival benefit observed with early revascularization and guide selection of patients for this strategy. METHODS AND RESULTS: One hundred seventy-five echocardiograms performed within 24 hours of randomization to the early revascularization (ERV) or initial medical stabilization (IMS) arms of the trial were submitted for quantitative assessment, and 169 were suitable for analysis. The 2 groups were similar in terms of clinical and early echocardiographic characteristics. Mean left ventricular ejection fraction (LVEF) was 31%, and moderate or greater mitral regurgitation (MR) was noted in 39.1%. On multivariate analysis, the only independent predictors of survival were MR severity and LVEF. A survival benefit for the ERV strategy was observed at all levels of LVEF and MR. CONCLUSIONS: A wide range of cardiac structural and functional abnormalities exists in patients presenting with acute cardiogenic shock. Both short- and long-term mortality appear to be associated with initial left ventricular systolic function and MR as assessed by echocardiography, and a benefit of ERV is noted regardless of baseline LVEF or MR
— id: 38911, year: 2003, vol: 107, page: 279, stat: Journal Article,

Poverty, process of care, and outcome in acute coronary syndromes
Rao, Sunil V; Kaul, Padma; Newby, L Kristin; Lincoff, A Michael; Hochman, Judith; Harrington, Robert A; Mark, Daniel B; Peterson, Eric D
2003 Jun 4;41(11):1948-1954, Journal of the American College of Cardiology
OBJECTIVES: We sought to determine whether income-based disparities in care processes and outcome exist in patients with acute coronary syndromes. BACKGROUND: Using income proxies and limited clinical data, some observational studies have shown income disparities in outcome after acute myocardial infarction (MI). METHODS: Using annual household income from the economic substudy of the PURSUIT (Platelet Glycoprotein IIB/IIIA In Unstable Angina: Receptor Suppression Using Integrilin Therapy) trial, patients were grouped into low-, middle-, and high-income categories based on the U.S. Census Bureau definition of poverty. Logistic regression analysis was used to examine the association between income category and the use of cardiac procedures and the prescription of evidence-based medications at hospital discharge. Cox regression analysis was used to examine the hazard of 30-day and six-month death or recurrent MI across income categories, after adjusting for baseline characteristics. RESULTS: Low-income patients had more chronic medical conditions and were sicker at presentation. Among low-income patients, the use of some evidence-based medications and cardiac procedures was lower and the unadjusted rates of 30-day death and six-month death or MI was higher. After multivariable adjustment, there was no consistent pattern for disparity in care processes, but the trend for higher short and intermediate-term death or MI persisted for low-income patients. CONCLUSIONS: Income level is associated with a trend toward worse outcome among patients with acute coronary syndromes. The disparity in 30-day and six-month death or MI between low and high-income patients could not be readily explained by differences in in-hospital medical or invasive treatment, suggesting that the poor outcomes may be due to differences occurring after hospital discharge
— id: 72019, year: 2003, vol: 41, page: 1948, stat: Journal Article,

Clinical and angiographic characteristics of patients with combined anterior and inferior ST-segment elevation on the initial electrocardiogram during acute myocardial infarction
Sadanandan, Saihari; Hochman, Judith S; Kolodziej, Allen; Criger, Douglas A; Ross, Alan; Selvester, Ronald; Wagner, Galen S
2003 Oct;146(4):653-661, American heart journal
OBJECTIVE: We evaluated the significance of combined anterior and inferior ST-segment elevation on the initial electrocardiogram (EKG) in patients with acute myocardial infarction (AMI) and correlated it with AMI size and left ventricular (LV) function. METHODS: We analyzed admission EKGs of 2996 patients with AMI from the GUSTO-I angiographic substudy and the GUSTO-IIb angioplasty substudy who underwent immediate angiography. In all, we identified 1046 patients with anterior ST elevation (ST-segment elevation in > or =2 of leads V1-V4) and divided them into 3 groups: Group 1, anterior + inferior ST elevation (ST elevation in > or =2 of leads II, III, aVF, n =179); Group 2, anterior ST elevation only (<2 of leads II, III, aVF with ST elevation or depression, n = 447); Group 3, anterior ST elevation + superior ST elevation (ST depression in > or =2 of leads II, III, aVF, n = 420). RESULTS: Cardiac risk factors, prior AMI, prior percutaneous transluminal coronary angioplasty or coronary artery bypass graft, Killip class, and thrombolytic therapy assignment did not differ among the 3 groups. Group 1 patients had greater number of leads with ST elevation compared to Groups 2 and 3 (ST elevation in > or =6 leads 83% vs 22% vs 49%, P =.001). Despite greater ST-segment elevation, Group 1 patients had a lower peak CK level (median baseline peak CK 1370 vs 1670 vs 2381 IU, P =.0001) and less LV dysfunction (median ejection fraction 0.53 vs 0.49 vs 0.45, P =.0001; median number of abnormal chords 21 vs 32 vs 40, P =.0001). Angiographically, Group 1 had 2 distinct subsets of patients with either right coronary artery (RCA) (59%) or left anterior descending coronary artery (LAD) (36%) occlusion. In contrast, the infarct-related artery (IRA) was almost entirely the LAD in Groups 2 and 3 (97%). Further, the site of IRA occlusion in Group 1 was mostly proximal RCA (67%) in the RCA subgroup and mid or distal LAD (70%) in the LAD subgroup. ST-segment elevation in lead V1 > or = V3 and absence of progression of ST elevation from lead V1 to V3 on the EKG differentiated IRA-RCA from IRA-LAD in patients with combined anterior and inferior ST elevation. CONCLUSIONS: The AMI size and LV dysfunction in patients with anterior ST elevation is directly related to the direction of ST segment deviation in the leads II, III, aVF; least with inferior ST elevation, intermediate with no ST deviation, and maximal with superior ST elevation (inferior ST depression). Despite greater ST-segment elevation, patients with combined anterior and inferior ST elevation have limited AMI size and preserved LV function. Angiographically, they comprise 2 distinct subsets with either proximal RCA or mid to distal LAD occlusion. A predominant right ventricular and limited inferior LV AMI from a proximal RCA occlusion, or a smaller anterior AMI from a more distal occlusion of LAD may explain their limited AMI size despite greater ST elevation
— id: 38900, year: 2003, vol: 146, page: 653, stat: Journal Article,

Correlates of one-year survival inpatients with cardiogenic shock complicating acute myocardial infarction: angiographic findings from the SHOCK trial
Sanborn, Timothy A; Sleeper, Lynn A; Webb, John G; French, John K; Bergman, Geoffrey; Parikh, Manish; Wong, S Chiu; Boland, Jean; Pfisterer, Matthias; Slater, James N; Sharma, Samin; Hochman, Judith S
2003 Oct 15;42(8):1373-1379, Journal of the American College of Cardiology
OBJECTIVES: The goal of this study was to describe the core laboratory angiographic findings of 'SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK' (SHOCK) trial participants and to determine the relationship of angiographic parameters to one-year survival. BACKGROUND: In the SHOCK trial, emergency revascularization improved one-year survival of patients with cardiogenic shock compared with initial medical stabilization including thrombolysis and intraaortic balloon counterpulsation. METHODS: Coronary angiography was performed by protocol in 147 of 152 (97%) patients in the emergency revascularization (ERV) group and by clinical selection in 100 of 150 (67%) patients in the initial medical stabilization (IMS) group. Of the other 50 IMS patients, 45 of 50 (90%) died rapidly and did not undergo angiography. RESULTS: Left ventricular ejection fraction was correlated with one-year survival in both treatment groups (p < 0.001). In the IMS group, the hazard ratio for death was 2.59 (95% confidence interval 1.47 to 4.58, p = 0.001) per diseased vessel (0/1 vs. 2 vs. 3). In the ERV group, the hazard ratio for death per diseased vessel was 1.11 (95% confidence interval 0.79 to 1.56, p = 0.559). Multivariate analysis of the angiography cohort (without regard for left ventriculogram measurements) identified initial Thrombolysis in Myocardial Infarction flow grade (p = 0.032), number of diseased vessels (for IMS patients only, p = 0.024), and culprit vessel (p = 0.004) as independent correlates of one-year survival, even after adjustment for key clinical factors. In the smaller cohort with left ventricular ejection fraction measured (n = 97), ejection fraction and culprit vessel remained independently correlated with survival. CONCLUSIONS: For patients in cardiogenic shock, left ventricular function and culprit vessel were independent correlates of one-year survival
— id: 38902, year: 2003, vol: 42, page: 1373, stat: Journal Article,

Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial
Webb, John G; Lowe, April M; Sanborn, Timothy A; White, Harvey D; Sleeper, Lynn A; Carere, Ronald G; Buller, Christopher E; Wong, S Chiu; Boland, Jean; Dzavik, Vlad; Porway, Mark; Pate, Gordon; Bergman, Geoffrey; Hochman, Judith S
2003 Oct 15;42(8):1380-1386, Journal of the American College of Cardiology
OBJECTIVES: We examined the clinical, angiographic, and procedural characteristics determining survival after percutaneous coronary intervention (PCI) for cardiogenic shock. BACKGROUND: The SHOCK (SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK?) trial prospectively enrolled patients with shock complicating acute myocardial infarction (MI). Patients were randomized to a strategy of early revascularization or initial medical stabilization. METHODS: Patients randomized to early revascularization underwent PCI or bypass surgery on the basis of predefined clinical criteria. Patients randomized to early revascularization who underwent PCI and had angiographic films available for analysis are the subject of this report (n = 82). RESULTS: The median time from MI to PCI was 11 h. The majority of patients had occluded culprit arteries (Thrombolysis In Myocardial Infarction [TIMI] grade 0 or 1 flow in 62%) and multivessel disease (81%). One-year mortality in PCI patients was 50%. Mortality was 39% if PCI was successful but 85% if unsuccessful (p < 0.001). Mortality was 38% if TIMI flow grade 3 was achieved, 55% with TIMI grade 2 flow, and 100% with TIMI grade 0 or 1 flow (p < 0.001). Mortality was 67% if severe mitral regurgitation was documented. Independent correlates of mortality were as follows: increasing age (p < 0.001), lower systolic blood pressure (p = 0.009), increasing time from randomization to PCI (p = 0.019), lower post-PCI TIMI flow (0/1 vs. 2/3) (p < 0.001), and multivessel PCI (p = 0.040). CONCLUSIONS: Restoration of coronary blood flow is a major predictor of survival in cardiogenic shock. Benefit appears to extend beyond the generally accepted 12-h post-infarction window. Surgery should be considered in shock patients with severe mitral insufficiency or multivessel disease not amenable to relatively complete percutaneous revascularization
— id: 38901, year: 2003, vol: 42, page: 1380, stat: Journal Article,

ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina)
Braunwald, Eugene; Antman, Elliott M; Beasley, John W; Califf, Robert M; Cheitlin, Melvin D; Hochman, Judith S; Jones, Robert H; Kereiakes, Dean; Kupersmith, Joel; Levin, Thomas N; Pepine, Carl J; Schaeffer, John W; Smith, Earl E 3rd; Steward, David E; Theroux, Pierre; Gibbons, Raymond J; Alpert, Joseph S; Faxon, David P; Fuster, Valentin; Gregoratos, Gabriel; Hiratzka, Loren F; Jacobs, Alice K; Smith, Sidney C Jr
2002 Oct 2;40(7):1366-1374, Journal of the American College of Cardiology
— id: 38914, year: 2002, vol: 40, page: 1366, stat: Journal Article,

ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)
Braunwald, Eugene; Antman, Elliott M; Beasley, John W; Califf, Robert M; Cheitlin, Melvin D; Hochman, Judith S; Jones, Robert H; Kereiakes, Dean; Kupersmith, Joel; Levin, Thomas N; Pepine, Carl J; Schaeffer, John W; Smith, Earl E 3rd; Steward, David E; Theroux, Pierre; Gibbons, Raymond J; Alpert, Joseph S; Faxon, David P; Fuster, Valentin; Gregoratos, Gabriel; Hiratzka, Loren F; Jacobs, Alice K; Smith, Sidney C Jr
2002 Oct 1;106(14):1893-1900, Circulation
— id: 38916, year: 2002, vol: 106, page: 1893, stat: Journal Article,

First experience with direct factor Xa inhibition in patients with stable coronary disease: a pharmacokinetic and pharmacodynamic evaluation
Dyke, Christopher K; Becker, Richard C; Kleiman, Neal S; Hochman, Judith S; Bovill, Edwin G; Lincoff, A Michael; Gerstenblith, Gary; Dzavik, Vladimir; Gardner, Laura H; Hasselblad, Vic; Zillman, Linda A; Shimoto, Yoshimasa; Robertson, Thomas L; Kunitada, Satoshi; Armstrong, Paul W; Harrington, Robert A
2002 May 21;105(20):2385-2391, Circulation
BACKGROUND: Thrombin generation is critical to the formation of an arterial thrombus after rupture of an atherosclerotic plaque. In patients with stable coronary disease receiving standard medical therapy, we evaluated the pharmacokinetics, pharmacodynamics, and safety profile of DX-9065a, a novel small-molecule anticoagulant that directly, selectively, and reversibly inhibits factor Xa. METHODS AND RESULTS: In a double-blind trial, 73 patients (median age, 63 years; 29% women) were randomly assigned to receive a fixed-dose intravenous bolus, followed by a 72-hour infusion of placebo or 1 of 4 weight-adjusted regimens of DX-9065a. Plasma samples were collected during infusion and a 24-hour elimination period. Only minor bleeding occurred, predominantly ecchymoses at infusion sites, and its incidence did not differ significantly among the groups, including placebo. Median hemoglobin, platelet count, serum creatinine level, and liver function tests did not change significantly from baseline during infusion or elimination. Significant predictors of pharmacokinetic response included infusion dose and weight. At 60 hours into the DX-9065a infusion, plasma drug levels correlated strongly with anti-factor Xa activity (r=0.97), prothrombin time (r=0.77), and international normalized ratio (r=0.72) but less so with activated partial thromboplastin time (r=0.56; all P<0.001). CONCLUSIONS: This is the first study of a selective, reversible, and direct small-molecule factor Xa inhibitor in patients with stable coronary disease. These data lay the foundation for further investigation of factor Xa inhibitors in the treatment of patients with coronary atherothrombosis
— id: 38918, year: 2002, vol: 105, page: 2385, stat: Journal Article,

Is glycoprotein IIb/IIIa antagonism as effective in women as in men following percutaneous coronary intervention?. Lessons from the ESPRIT study
Fernandes, Laura S; Tcheng, James E; O'Shea, J Conor; Weiner, Bonnie; Lorenz, Todd J; Pacchiana, Cindy; Berdan, Lisa G; Maresh, Kelly J; Joseph, Diane; Madan, Mina; Mann, Tift; Kilaru, Rakhi; Hochman, Judith S; Kleiman, Neal S
2002 Sep 18;40(6):1085-1091, Journal of the American College of Cardiology
OBJECTIVE: The study was done to determine whether eptifibatide, a platelet glycoprotein (GP) IIb/IIIa antagonist, prevents ischemic complications following percutaneous coronary interventions (PCIs) in women as well as in men. BACKGROUND: Eptifibatide reduces ischemic complications after nonurgent coronary stent interventions. METHODS: We compared outcomes in women (n = 562) and men (n = 1,502) enrolled in the Enhanced Suppression of the Platelet GP IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) trial of double-bolus eptifibatide during PCI. RESULTS: Women in the ESPRIT trial were older, and more frequently had hypertension, diabetes mellitus, or acute coronary syndromes, but were less likely to have prior PCI or coronary artery bypass graft surgery. The primary end point, a composite at 48 h of death, myocardial infarction (MI), urgent target vessel revascularization (TVR), and unplanned GP IIb/IIIa use, occurred in 10.5% of women and 7.9% of men (p = 0.082). The composite of death, MI, or TVR after one year occurred in 24.5% of women compared with 18% of men (p = 0.0008). At 48 h, eptifibatide reduced the composite of death, MI, and TVR from 14.5% to 6.0% in women versus 9.0% to 6.8% in men. At one year, these differences persisted: 28.9% versus 20.0% for women and 19.5% versus 16.6% for men. No statistical interaction existed between treatment and gender at either 48 h (p = 0.063) or one year (p = 0.2). Bleeding occurred more commonly in women (5.5% vs. 2.6%, p = 0.002), and was more common in eptifibatide-treated women. After adjustment for age, weight, and hypertension, no interaction between treatment and gender was present. CONCLUSION: Eptifibatide is effective to prevent ischemic complications of PCI in women and may eliminate gender-related differences in PCI outcomes
— id: 38917, year: 2002, vol: 40, page: 1085, stat: Journal Article,

Association of C-reactive protein and serum amyloid A with recurrent coronary events in stable patients after healing of acute myocardial infarction
Harb, Tareq S; Zareba, Wojciech; Moss, Arthur J; Ridker, Paul M; Marder, Victor J; Rifai, Nader; Miller Watelet, Luc F; Arora, Rohit; Brown, Mary W; Case, Robert B; Dwyer, Edward M Jr; Gillespie, John A; Goldstein, Robert E; Greenberg, Henry; Hochman, Judith; Krone, Ronald J; Liang, Chang Seng; Lichstein, Edgar; Little, William; Marcus, Frank I; Oakes, David; Sparks, Charles E; VanVoorhees, Lucy
2002 Jan 15;89(2):216-221, American journal of cardiology
— id: 72020, year: 2002, vol: 89, page: 216, stat: Journal Article,

Acute coronary syndromes: does sex matter?
Hochman, Judith S; Tamis-Holland, Jacqueline E
2002 Dec 25;288(24):3161-3164, JAMA
— id: 38912, year: 2002, vol: 288, page: 3161, stat: Journal Article,

The Determinants of Activated Partial Thromboplastin Time, Relation of Activated Partial Thromboplastin Time to Clinical Outcomes, and Optimal Dosing Regimens for Heparin Treated Patients with Acute Coronary Syndromes: A Review of GUSTO-IIb
Lee, Michael S; Wali, Andreas U; Menon, Venu; Berkowitz, Scott D; Thompson, Trevor D; Califf, Robert M; Topol, Eric J; Granger, Christopher B; Hochman, Judith S
2002 Oct;14(2):91-101, Journal of thrombosis & thrombolysis
Context: Unfractionated heparin remains widely utilized in the treatment of acute coronary syndromes (ACS). However, limited data exist on optimal dosing and range of activated partial thromboplastin time (aPTT) in this setting. A large trial of thrombolysis for acute myocardial infarction has reported an association between longer aPTTs and adverse outcomes.Objectives: Estimate the optimal heparin-dosing regimen in achieving early therapeutic aPTTs (50 to 75 seconds) and determine the association of aPTT and death, reinfarction, and bleeding in population with ACS.Design: Subgroup analysis within a randomized, controlled trial of 5861 patients given unfractionated heparin who had aPTTs at 6, 12, or 24 hours, with outcome analyses by weight categories.Setting: In 373 hospitals in 13 countries from May 1994 to October 1995.Patients: A total of 12,142 patients admitted for ACS, stratified by the presence (n = 4131) or absence (n = 8011) of ST-segment elevation, and randomized to 72 hours of unfractionated heparin.Results: In a simulated weight-adjusted model, based on retrospective grouping by weight, a simulated dose of 60-U/kg bolus and 12-U/kg/h infusion resulted in the highest proportion of therapeutic aPTTs. After adjustment for baseline variables, longer 12-hour aPTT was associated with the composite of 30-day death or reinfarction in patients not treated with thrombolytic therapy (odds ratio, 1.10; 95% CI, 1.00 to 1.22; P = 0.047). Longer aPTT at 6 hours was associated with increased moderate or severe bleeding for the entire cohort. There was also a significant, nonlinear correlation of the 12-hour aPTT with moderate or severe bleeding in thrombolysis-treated patients.Conclusions: For ACS patients who are treated with heparin, aPTT is highly associated with body weight. Longer aPTT within the first 12 hours is associated with adverse outcomes in ACS. Heparin dosing for ACS should be weight based
— id: 38908, year: 2002, vol: 14, page: 91, stat: Journal Article,

Mortality at 1 year with combination platelet glycoprotein IIb/IIIa inhibition and reduced-dose fibrinolytic therapy vs conventional fibrinolytic therapy for acute myocardial infarction: GUSTO V randomized trial
Lincoff, A Michael; Califf, Robert M; Van de Werf, Frans; Willerson, James T; White, Harvey D; Armstrong, Paul W; Guetta, Victor; Gibler, W Brian; Hochman, Judith S; Bode, Christoph; Vahanian, Alec; Steg, P Gabriel; Ardissino, Diego; Savonitto, Stefano; Bar, Frits; Sadowski, Zygmunt; Betriu, Amadeo; Booth, Joan E; Wolski, Kathy; Waller, Michael; Topol, Eric J
2002 Nov 6;288(17):2130-2135, JAMA
CONTEXT: Among patients with acute myocardial infarction, combination reperfusion therapy with a platelet glycoprotein IIb/IIIa receptor inhibitor (abciximab) and a half dose of a plasminogen activator (reteplase) did not significantly reduce mortality at 30 days compared with a full dose of reteplase. Rates of nonfatal ischemic complications were significantly diminished. OBJECTIVE: To determine if the beneficial effects of abciximab and reteplase (combination therapy) on early nonfatal complications would translate into a reduction in the risk of death by 1 year. DESIGN, SETTING, AND PATIENTS: One-year follow-up of a randomized controlled trial (Global Use of Strategies To Open Coronary Arteries [GUSTO] V). Of 16 588 patients who had been treated in 820 community and referral hospitals in 20 countries between July 1999 and February 2001, mortality data were available for 16 453 (99.2%). INTERVENTION: Patients were randomly assigned to receive (intravenously) a standard dose of reteplase (two 10-U boluses, 30 minutes apart) or the combination of a standard dose of abciximab (0.25 mg/kg bolus, 0.125 microg/kg per minute infusion [maximum 10 micro g/min for 12 hours]) and a half dose of reteplase (two 5-U boluses, 30 minutes apart). MAIN OUTCOME MEASURE: One-year all-cause mortality rates. RESULTS: All-cause mortality at 1 year occurred in 692 (8.38%) of 8260 patients in the reteplase group and 698 (8.38%) of the 8328 patients in the combination therapy group (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.90-1.11; P>.99). Reinfarction within the first 7 days occurred in 3.5% of patients in the reteplase group and 2.3% of patients in the combination therapy group, and was significantly associated with 1-year mortality (22.6% in patients with reinfarction vs 8.0% in patients without reinfarction; HR, 3.08; 95% CI, 2.53-3.75; P<.001). However, treatment assignment did not significantly influence time of mortality regardless of reinfarction status. CONCLUSION: Combination therapy (abciximab and reteplase) did not reduce mortality over 1 year compared with fibrinolytic therapy with reteplase alone
— id: 38913, year: 2002, vol: 288, page: 2130, stat: Journal Article,

Management of cardiogenic shock complicating acute myocardial infarction
Menon, Venu; Hochman, Judith S
2002 Nov;88(5):531-537, Heart (British Cardiac Society)
— id: 38915, year: 2002, vol: 88, page: 531, stat: Journal Article,

An automated strategy for bedside aPTT determination and unfractionated heparin infusion adjustment in acute coronary syndromes: insights from PARAGON A
Newby, L Kristin; Harrington, Robert A; Bhapkar, Manjushri V; Van de Werf, Frans; Hochman, Judith S; Granger, Christopher B; Simes, R John; Davis, Catherine G; Topol, Eric J; Califf, Robert M; Moliterno, David J
2002 Aug;14(1):33-42, Journal of thrombosis & thrombolysis
BACKGROUND: Intravenous unfractionated heparin remains a cornerstone of anticoagulation therapy for patients with acute coronary syndromes, but regulation to a target aPTT is challenging. We assessed unfractionated heparin infusion regulation by bedside, whole-blood aPTT testing and computerized, algorithmic infusion adjustment, and further evaluated the relationship of achieving the target aPTT with clinical outcomes. METHODS AND RESULTS: We studied 1,275 patients randomized to unfractionated heparin in PARAGON-A, which tested lamifiban with or without unfractionated heparin versus unfractionated heparin. All patients had baseline and 6-hour blinded, bedside aPTTs, then aPTTs per algorithm. A central computer translated encrypted values to algorithmic dose-adjustment commands. We assessed the ability to achieve and maintain aPTTs of 50-70 seconds and associations of 6- and 12-hour aPTTs and time-to-target with 30-day outcomes.Overall, the median 6-hour aPTT was 50-70 seconds and remained so throughout infusion. Individually, only 33.6% of patients achieved 6-hour target-range aPTTs, and only 40% of all aPTTs were in-range. After achieving target, only 42% of subsequent measures were in-range. Thirty-day death or myocardial infarction (death/MI) increased non-significantly as time-to-target increased (p = 0.08). Thirty-day mortality was similar if target aPTT was reached, regardless of timing. Death/MI trended lower if target aPTT was reached by 8 hours (p = 0.10). The best clinical outcomes were associated with in-range aPTTs. CONCLUSIONS: This study represents the most systematic monitoring and regulation of unfractionated heparin anticoagulation to date. Although average anticoagulation achieved target range, wide inter- and intra-patient variability may have important implications for clinical outcomes
— id: 38910, year: 2002, vol: 14, page: 33, stat: Journal Article,

Atrial fibrillation and mortality among patients with acute coronary syndromes without ST-segment elevation: results from the PURSUIT trial
Al-Khatib SM; Pieper KS; Lee KL; Mahaffey KW; Hochman JS; Pepine CJ; Kopecky SL; Akkerhuis M; Stepinska J; Simoons ML; Topol EJ; Califf RM; Harrington RA
2001 Jul 1;88(1):A7, 76-9, American journal of cardiology
— id: 38922, year: 2001, vol: 88, page: A7, 76, stat: Journal Article,

American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on cardiac catheterization laboratory standards. A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents
Bashore TM; Bates ER; Berger PB; Clark DA; Cusma JT; Dehmer GJ; Kern MJ; Laskey WK; O'Laughlin MP; Oesterle S; Popma JJ; O'Rourke RA; Abrams J; Bates ER; Brodie BR; Douglas PS; Gregoratos G; Hlatky MA; Hochman JS; Kaul S; Tracy CM; Waters DD; Winters WL Jr
2001 Jun 15;37(8):2170-2214, Journal of the American College of Cardiology
— id: 38923, year: 2001, vol: 37, page: 2170, stat: Journal Article,

Trends in cardiogenic shock: report from the SHOCK Study. The SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?
Carnendran L; Abboud R; Sleeper LA; Gurunathan R; Webb JG; Menon V; Dzavik V; Cocke T; Hochman JS
2001 Mar;22(6):472-478, European heart journal
AIMS: We analysed time trends in patient characteristics, management, and outcomes of cardiogenic shock complicating acute myocardial infarction in the international, prospective SHOCK Trial Registry and pre-study Registry. BACKGROUND: Despite therapeutic advances in its management, the incidence and high mortality of this complication has remained unchanged for decades. However, in recent years mortality was reported to decrease in one community concomitant with increasing use of revascularization. METHODS: Thirty-six centres registered 1380 patients with suspected cardiogenic shock complicating acute myocardial infarction from January 1992 to August 1997. Patient and myocardial infarction characteristics, haemodynamics, medications, procedure use, and vital status at discharge were recorded. RESULTS: In all, 79% of patients had shock due to predominant pump failure (non-mechanical aetiology). The aetiology, patient profile, and clinical characteristics of cardiogenic shock did not differ over time, except for increases in the incidence of prior bypass surgery (P=0.054) and transfers to tertiary centres (P=0.008). In all, 44% underwent revascularization (n=485), with angioplasty performed more often than bypass surgery (69% vs 31%). The revascularization rate increased over time (P=0.006) with a significant decrease in the time to revascularization (P=0.033). The use of Swan-Ganz catheterization decreased over time (P=0.018), as did the mean length of hospitalization (P=0.034). Overall in-hospital mortality was high (63%) but decreased over time in all patients (P=0.004) and those with pump failure (P=0.018). Mortality was lower for patients who underwent revascularization compared to those who were not revascularized (41% vs 79%, P<0.001). CONCLUSIONS: Cardiogenic shock complicating acute myocardial infarction is associated with a high mortality rate, but mortality decreased significantly from 1992 to 1997. This partly reflects the greater use of revascularization, which was associated with better outcomes. The reported international trend towards shorter admissions for myocardial infarction was also observed in this cohort
— id: 38927, year: 2001, vol: 22, page: 472, stat: Journal Article,

One-year survival following early revascularization for cardiogenic shock
Hochman JS; Sleeper LA; White HD; Dzavik V; Wong SC; Menon V; Webb JG; Steingart R; Picard MH; Menegus MA; Boland J; Sanborn T; Buller CE; Modur S; Forman R; Desvigne-Nickens P; Jacobs AK; Slater JN; LeJemtel TH
2001 Jan 10;285(2):190-192, JAMA
CONTEXT: Cardiogenic shock (CS) is the leading cause of death for patients hospitalized with acute myocardial infarction (AMI). OBJECTIVE: To assess the effect of early revascularization (ERV) on 1-year survival for patients with AMI complicated by CS. DESIGN: The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) Trial, an unblinded, randomized controlled trial from April 1993 through November 1998. SETTING: Thirty-six referral centers with angioplasty and cardiac surgery facilities. PATIENTS: Three hundred two patients with AMI and CS due to predominant left ventricular failure who met specified clinical and hemodynamic criteria. INTERVENTIONS: Patients were randomly assigned to an initial medical stabilization (IMS; n = 150) group, which included thrombolysis (63% of patients), intra-aortic balloon counterpulsation (86%), and subsequent revascularization (25%), or to an ERV group (n = 152), which mandated revascularization within 6 hours of randomization and included angioplasty (55%) and coronary artery bypass graft surgery (38%). MAIN OUTCOME MEASURES: All-cause mortality and functional status at 1 year, compared between the ERV and IMS groups. RESULTS: One-year survival was 46.7% for patients in the ERV group compared with 33.6% in the IMS group (absolute difference in survival, 13.2%; 95% confidence interval [CI], 2.2%-24.1%; P<.03; relative risk for death, 0.72; 95% CI, 0.54-0.95). Of the 10 prespecified subgroup analyses, only age (<75 vs >/= 75 years) interacted significantly (P<.03) with treatment in that treatment benefit was apparent only for patients younger than 75 years (51.6% survival in ERV group vs 33.3% in IMS group). Eighty-three percent of 1-year survivors (85% of ERV group and 80% of IMS group) were in New York Heart Association class I or II. CONCLUSIONS: For patients with AMI complicated by CS, ERV resulted in improved 1-year survival. We recommend rapid transfer of patients with AMI complicated by CS, particularly those younger than 75 years, to medical centers capable of providing early angiography and revascularization procedures
— id: 38019, year: 2001, vol: 285, page: 190, stat: Journal Article,

New heparin dosing recommendations for patients with acute coronary syndromes
Menon V; Berkowitz SD; Antman EM; Fuchs RM; Hochman JS
2001 Jun 1;110(8):641-650, American journal of medicine
Despite major innovations in antithrombotic and antiplatelet therapy, unfractionated intravenous heparin is widely used to treat acute coronary syndromes. Recommendations for unfractionated heparin dosing in acute myocardial infarction and unstable angina have been issued in two recent American College of Cardiology/American Heart Association guidelines. An initial heparin bolus of 60 U/kg (maximum, 4000 U) followed by a 12-U/kg/h infusion (maximum 1000 U/h) is recommended with alteplase for ST-elevation myocardial infarction. When intravenous heparin is administered for myocardial infarction with non-ST elevation and unstable angina, an initial bolus of 60 to 70 U/kg (maximum, 5000 U) followed by a 12- to 15-U/kg/h infusion is recommended. The goal is to achieve an activated partial thromboplastin time of 50 to 70 seconds. Here, we review these new dosing regimens and explain the rationale for their use. We also review the risk of bleeding with heparin, especially when administered concurrently with aspirin, thrombolytic agents, and glycoprotein IIb/IIIa antagonists, and the relationship between activated partial thromboplastin time and cardiac events
— id: 38924, year: 2001, vol: 110, page: 641, stat: Journal Article,

New approaches to diagnosis and management of unstable angina and non-ST-segment elevation myocardial infarction
O'Rourke RA; Hochman JS; Cohen MC; Lucore CL; Popma JJ; Cannon CP
2001 Mar 12;161(5):674-682, Archives of internal medicine
Recently, it has been demonstrated in multiple clinical research studies that non-Q-wave myocardial infarction shares many of the features of unstable angina pectoris and that both diseases initially are managed similarly. Important new antiplatelet drugs (glycoprotein IIb-IIIa inhibitors) and antithrombin agents (low-molecular-weight heparin) are currently recommended for patients with unstable angina pectoris/non-ST-segment elevation MI who are at high or intermediate risk on the basis of symptoms, electrocardiographic findings, and the presence or absence of serum markers (eg, troponin I, troponin T, and creatine kinase-MB). This review provides important information concerning the results of clinical studies of glycoprotein IIb-IIIa inhibitors (tirofiban hydrochloride and eptifibatide) when used with unfractionated heparin in patients with this syndrome or with low-molecular weight heparin (enoxaparin sodium) in similar patients. The Thrombolysis in Myocardial Infarction IIIB, Veterans Affairs Non-Q-Wave Infarction Studies in Hospital, and Fast Revascularization During Instability in Coronary Artery Disease II studies evaluating a conservative, ischemia-guided approach vs an early aggressive approach to such patients are presented, with a practical algorithm for treating such patients
— id: 38926, year: 2001, vol: 161, page: 674, stat: Journal Article,

Aortic counterpulsation in acute myocardial infarction: physiologically important but does the patient benefit?
Ohman EM; Hochman JS
2001 Jun;141(6):889-892, American heart journal
— id: 38925, year: 2001, vol: 141, page: 889, stat: Journal Article,

Comparison of benefits and complications of hirudin versus heparin for patients with acute coronary syndromes undergoing early percutaneous coronary intervention
Roe MT; Granger CB; Puma JA; Hellkamp AS; Hochman JS; Ohman EM; White HD; Van de Werf F; Armstrong PW; Ellis SG; Califf RM; Topol EJ
2001 Dec 15;88(12):1403-6, A6, American journal of cardiology
— id: 38919, year: 2001, vol: 88, page: 1403, stat: Journal Article,

The late open artery hypothesis--a decade later
Sadanandan S; Buller C; Menon V; Dzavik V; Terrin M; Thompson B; Lamas G; Hochman JS
2001 Sep;142(3):411-421, American heart journal
BACKGROUND: Early reperfusion after myocardial infarction has been proved to preserve left ventricular function and reduce mortality. However, a significant number of patients have persistent occlusion of the infarct-related artery late (days to weeks) after myocardial infarction because of ineligibility for thrombolytic therapy, failure of reperfusion, or reocclusion. METHODS: In this report we review the data on the potential mechanisms and benefits of late reperfusion and present prospective data on the incidence of and current practice patterns for the management of persistently occluded infarct-related arteries late after myocardial infarction. RESULTS: Although several studies have associated late patency of the infarct-related artery with improved long-term clinical outcome, they were nonrandomized and reflect selection bias. Furthermore, data on late patency from the largest study, Global Utilization of Steptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO-I), failed to confirm independent benefits of an open infarct-related artery 1 year after myocardial infarction. The randomized data on the effects of percutaneous transluminal coronary angioplasty for occluded infarct-related arteries late after myocardial infarction are limited and inconclusive. CONCLUSIONS: The hypothesis that late reperfusion by percutaneous coronary intervention days to weeks after myocardial infarction results in improved long-term clinical outcomes in asymptomatic patients with occluded infarct-related artery is currently being tested in the randomized, multicenter Occluded Artery Trial
— id: 38921, year: 2001, vol: 142, page: 411, stat: Journal Article,

Percutaneous coronary intervention for cardiogenic shock in the SHOCK Trial Registry
Webb JG; Sanborn TA; Sleeper LA; Carere RG; Buller CE; Slater JN; Baran KW; Koller PT; Talley JD; Porway M; Hochman JS
2001 Jun;141(6):964-970, American heart journal
BACKGROUND: The SHOCK Registry prospectively enrolled patients with cardiogenic shock complicating acute myocardial infarction in 36 multinational centers. METHODS: Cardiogenic shock was predominantly attributable to left ventricular pump failure in 884 patients. Of these, 276 underwent percutaneous coronary intervention (PCI) after shock onset and are the subject of this report. RESULTS: The majority (78%) of patients undergoing angiography had multivessel disease. As the number of diseased arteries rose from 1 to 3, mortality rates rose from 34.2% to 51.2%. Patients who underwent PCI had lower in-hospital mortality rates than did patients treated medically (46.4% vs 78.0%, P < .001), even after adjustment for patient differences and survival bias (P = .037). Before PCI, the culprit artery was occluded (Thrombolysis In Myocardial Infarction grade 0 or 1 flow) in 76.3%. After PCI, the in-hospital mortality rate was 33.3% if reperfusion was complete (grade 3 flow), 50.0% with incomplete reperfusion (grade 2 flow), and 85.7% with absent reperfusion (grade 0 or 1 flow) (P < .001). CONCLUSIONS: This prospective, multicenter registry of patients with acute myocardial infarction complicated by cardiogenic shock is consistent with a reduction in mortality rates as the result of percutaneous coronary revascularization. Coronary artery patency was an important predictor of outcome. Measures to promote early and rapid reperfusion appear critically important in improving the otherwise poor outcome associated with cardiogenic shock
— id: 38018, year: 2001, vol: 141, page: 964, stat: Journal Article,

Absence of gender differences in clinical outcomes in patients with cardiogenic shock complicating acute myocardial infarction. A report from the SHOCK Trial Registry
Wong SC; Sleeper LA; Monrad ES; Menegus MA; Palazzo A; Dzavik V; Jacobs A; Jiang X; Hochman JS
2001 Nov 1;38(5):1395-1401, Journal of the American College of Cardiology
OBJECTIVES: The aim of this study was to assess the impact of gender on clinical course and in-hospital mortality in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). BACKGROUND: Previous studies have demonstrated higher mortality for women compared with men with ST elevation myocardial infarctions and higher rates of CS after AMI. The influence of gender and its interaction with various treatment strategies on clinical outcomes once CS develops is unclear. METHODS: Using the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) Registry database of 1,190 patients with suspected CS in the setting of AMI, we examined shock etiologies by gender. Among the 884 patients with predominant left ventricular (LV) failure, we compared the patient demographics, angiographic and hemodynamic findings, treatment approaches as well as the clinical outcomes of women versus men. This study had a 97% power to detect a 10% absolute difference in mortality by gender. RESULTS: Left ventricular failure was the most frequent cause of CS for both gender groups. Women in the SHOCK Registry had a significantly higher incidence of mechanical complications including ventricular septal rupture and acute severe mitral regurgitation. Among patients with predominant LV failure, women were, on average, 4.6 years older, had a higher incidence of hypertension, diabetes and a lower cardiac index. The overall mortality rate for the entire cohort was high (61%). After adjustment for differences in patient demographics and treatment approaches, there was no significant difference in in-hospital mortality between the two gender groups (odds ratio = 1.03, 95% confidence interval of 0.73 to 1.43, p = 0.88). Mortality was also similar for women and men who were selected for revascularization (44% vs. 38%, p = 0.244). CONCLUSIONS: Women with CS complicating AMI had more frequent adverse clinical characteristics and mechanical complications. Women derived the same benefit as men from revascularization, and gender was not independently associated with in-hospital mortality in the SHOCK Registry
— id: 38920, year: 2001, vol: 38, page: 1395, stat: Journal Article,

ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)
Braunwald E; Antman EM; Beasley JW; Califf RM; Cheitlin MD; Hochman JS; Jones RH; Kereiakes D; Kupersmith J; Levin TN; Pepine CJ; Schaeffer JW; Smith EE 3rd; Steward DE; Theroux P; Alpert JS; Eagle KA; Faxon DP; Fuster V; Gardner TJ; Gregoratos G; Russell RO; Smith SC Jr
2000 Sep;36(3):970-1062, Journal of the American College of Cardiology
— id: 38931, year: 2000, vol: 36, page: 970, stat: Journal Article,

ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with unstable angina)
Braunwald E; Antman EM; Beasley JW; Califf RM; Cheitlin MD; Hochman JS; Jones RH; Kereiakes D; Kupersmith J; Levin TN; Pepine CJ; Schaeffer JW; Smith EE 3rd; Steward DE; Theroux P; Gibbons RJ; Alpert JS; Eagle KA; Faxon DP; Fuster V; Gardner TJ; Gregoratos G; Russell RO; Smith SC Jr
2000 Sep 5;102(10):1193-1209, Circulation
— id: 38941, year: 2000, vol: 102, page: 1193, stat: Journal Article,

Effect of very early angiotensin-converting enzyme inhibition on left ventricular dilation after myocardial infarction in patients receiving thrombolysis: results of a meta-analysis of 845 patients. FAMIS, CAPTIN and CATS Investigators
de Kam PJ; Voors AA; van den Berg MP; van Veldhuisen DJ; Brouwer J; Crijns HJ; Borghi C; Ambrosioni E; Hochman JS; LeJemtel TH; Kingma JH; Sutton MS; van Gilst WH
2000 Dec;36(7):2047-2053, Journal of the American College of Cardiology
OBJECTIVES: We sought to investigate the effect of angiotensin-converting enzyme (ACE) inhibition <9 h after myocardial infarction (MI) on left ventricular (LV) dilation in patients receiving thrombolysis. BACKGROUND: The ACE inhibitors reduce mortality after MI. Attenuation of LV dilation has been suggested as an important mechanism. METHODS: The data of 845 patients with three-month echocardiographic follow-up after MI were combined from three randomized, double-blind, placebo-controlled studies. The criteria for these studies included: 1) thrombolytic therapy; 2) ACE inhibition within 6 to 9 h; and 3) evaluation of LV dilation as the primary objective. RESULTS: The ACE inhibitor was started 3.2+/-1.7 h after the patients' first (mainly, 85%) anterior MI. After three months, LV dilation was not significantly attenuated by very early treatment with an ACE inhibitor. The diastolic volume index was attenuated by 0.5 ml/m2 (95% confidence interval [CI] -1.5 to 2.5, p = 0.61), and the systolic volume index by 0.5 ml/m2 (95% CI -1.0 to 1.9, p = 0.50). Subgroup analysis demonstrated that LV dilation was significantly attenuated by ACE inhibitor treatment for patients in whom reperfusion failed. In contrast, LV dilation was almost unaffected by ACE inhibitor treatment in successfully reperfused patients. CONCLUSIONS: We could not demonstrate attenuation of LV dilation in patients receiving thrombolysis by ACE inhibitor treatment within 6 to 9 h after MI. We speculate that very early treatment with an ACE inhibitor has a beneficial effect on LV remodeling only in patients in whom reperfusion failed. Other mechanisms may be responsible for the beneficial effects of ACE inhibitors in successfully reperfused patients after MI
— id: 38928, year: 2000, vol: 36, page: 2047, stat: Journal Article,

Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction
Hasdai D; Califf RM; Thompson TD; Hochman JS; Ohman EM; Pfisterer M; Bates ER; Vahanian A; Armstrong PW; Criger DA; Topol EJ; Holmes DR Jr
2000 Jan;35(1):136-143, Journal of the American College of Cardiology
OBJECTIVES: This study characterized clinical factors predictive of cardiogenic shock developing after thrombolytic therapy for acute myocardial infarction (AMI). BACKGROUND: Cardiogenic shock remains a common and ominous complication of AMI. By identifying patients at risk of developing shock, preventive measures may be implemented to avert its development. METHODS: We analyzed baseline variables associated with the development of shock after thrombolytic therapy in the Global Utilization of Streptikonase and Tissue-Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial. Using a Cox proportional hazards model, we devised a scoring system predicting the risk of shock. This model was then validated in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III) cohort. RESULTS: Shock developed in 1,889 patients a median of 11.6 h after enrollment. The major factors associated with increased adjusted risk of shock were age (chi2 = 285, hazard ratio [95% confidence interval] 1.47 [1.40, 1.53]), systolic blood pressure (chi2 = 280), heart rate (chi2 = 225) and Killip class (chi2 = 161, hazard ratio 1.70 [1.52, 1.90] and 2.95 [2.39, 3.63] for Killip II versus I and Killip III versus I, respectively) upon presentation. Together, these four variables accounted for >85% of the predictive information. These findings were transformed into an algorithm with a validated concordance index of 0.758. Applied to the GUSTO-III cohort, the four variables accounted for > 95% of the predictive information, and the validated concordance index was 0.796. CONCLUSIONS: A scoring system accurately predicts the risk of shock after thrombolytic therapy for AMI based primarily on the patient's age and physical examination on presentation
— id: 38945, year: 2000, vol: 35, page: 136, stat: Journal Article,

Platelet glycoprotein IIb/IIIa blockade and outcome of cardiogenic shock complicating acute coronary syndromes without persistent ST-segment elevation
Hasdai D; Harrington RA; Hochman JS; Califf RM; Battler A; Box JW; Simoons ML; Deckers J; Topol EJ; Holmes DR Jr
2000 Sep;36(3):685-692, Journal of the American College of Cardiology
OBJECTIVES: The study examined whether antiplatelet treatment with eptifibatide affected the frequency and outcome of shock among patients in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial who had acute coronary syndromes but not persistent ST-segment elevation. BACKGROUND: Preliminary reports suggest a salutary effect of antiplatelet agents when shock complicates acute myocardial infarction. METHODS: We analyzed the impact of antiplatelet treatment with eptifibatide on the frequency and outcome of cardiogenic shock developing after enrollment. PURSUIT was a double-blind, randomized trial that examined the efficacy of eptifibatide (180 microg/kg bolus + continuous infusion of 2.0 microg/kg/min for < or =96 h) versus placebo among patients who had acute coronary syndromes but not persistent ST-segment elevation. RESULTS: Shock developed in 2.5% of the 9,449 patients at a median (25th, 75th interquartiles) of 94.0 (38, 206) h. Death by 30 days occurred in 65.8% of shock patients. Patients who had acute myocardial infarction upon enrollment had a greater incidence of shock (2.9% vs. 2.1%, p = 0.01), developed shock earlier (40.2% <48 h vs. 20.9%, p = 0.001), and had higher 30-day mortality from shock (77.2% vs. 52.7%, p = 0.001). Randomization to eptifibatide did not affect the occurrence of shock (p = 0.71, adjusted odds ratio [OR] = 0.95, 95% confidence interval [CI] = 0.72-1.25). However, shock patients treated with eptifibatide had significantly reduced adjusted odds of 30-day death (p = 0.03, adjusted OR = 0.51, 95% CI = 0.28-0.94). CONCLUSIONS: Patients with shock treated with eptifibatide had significantly reduced adjusted odds of death, suggesting a salutary effect of antiplatelet therapy on shock. This finding warrants verification in specifically designed studies
— id: 38932, year: 2000, vol: 36, page: 685, stat: Journal Article,

Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?
Hochman JS; Buller CE; Sleeper LA; Boland J; Dzavik V; Sanborn TA; Godfrey E; White HD; Lim J; LeJemtel T
2000 Sep;36(3 Suppl A):1063-1070, Journal of the American College of Cardiology
OBJECTIVES: This SHOCK Study report seeks to provide an overview of patients with cardiogenic shock (CS) complicating acute myocardial infarction (MI) and the outcome with various treatments. The outcome of patients undergoing revascularization in the SHOCK Trial Registry and SHOCK Trial are compared. BACKGROUND: Cardiogenic shock is the leading cause of death in patients hospitalized for acute MI. The randomized SHOCK Trial reported improved six-month survival with early revascularization. METHODS: Patients with CS complicating acute MI who were not enrolled in the concurrent randomized trial were registered. Patient characteristics were recorded as were procedures and vital status at hospital discharge. RESULTS: Between April 1993 and August 1997, 1,190 patients with CS were registered and 232 were randomized in the SHOCK Trial. Predominant left ventricular failure (78.5%) was most common, with isolated right ventricular shock in 2.8%, severe mitral regurgitation in 6.9%, ventricular septal rupture in 3.9% and tamponade in 1.4%. In-hospital Registry mortality was 60%, with ventricular septal rupture associated with a significantly higher mortality (87.3%) than all other categories (p < 0.01). The risk profile and mortality were lower for Registry patients who were managed with thrombolytic therapy and/or intra-aortic balloon counter-pulsation, coronary angiography, angioplasty and/or coronary artery bypass surgery. After adjusting for these differences, the extent to which survival was improved with early revascularization was similar to that observed in the randomized SHOCK Trial. CONCLUSIONS: In this prospective Registry the etiology of CS was a mechanical complication in 12%. The similarity of the beneficial treatment effect in patients undergoing early revascularization in the SHOCK Trial Registry and SHOCK Trial provides strong support for the generalizability of the SHOCK Trial results
— id: 38940, year: 2000, vol: 36, page: 1063, stat: Journal Article,

Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK?
Jacobs AK; French JK; Col J; Sleeper LA; Slater JN; Carnendran L; Boland J; Jiang X; LeJemtel T; Hochman JS
2000 Sep;36(3 Suppl A):1091-1096, Journal of the American College of Cardiology
OBJECTIVES: We sought to determine the outcomes of patients with cardiogenic shock (CS) complicating non-ST-segment elevation acute myocardial infarction (MI). BACKGROUND: Such patients represent a high-risk (ST-segment depression) or low-risk (normal or nonspecific electrocardiographic findings) group for whom optimal therapy, particularly in the setting of shock, is unknown. METHODS: We assessed characteristics and outcomes of 881 patients with CS due to predominant left ventricular (LV) dysfunction in the SHOCK Trial Registry. RESULTS: Patients with non-ST-segment elevation MI (n = 152) were significantly older and had significantly more prior MI, heart failure, azotemia, bypass surgery, and peripheral vascular disease than patients with ST-elevation MI (n = 729). On average, the groups had similar in-hospital LV ejection fractions (approximately 30%), but patients with non-ST-elevation MI had a lower highest creatine kinase and were more likely to have triple-vessel disease. Among patients selected for coronary angiography, the left circumflex artery was the culprit vessel in 34.6% of non-ST-elevation versus 13.4% of ST-elevation MI patients (p = 0.001). Despite having more recurrent ischemia (25.7% vs. 17.4%, p = 0.058), non-ST-elevation patients underwent angiography less often (52.6% vs. 64.1%, p = 0.010). The proportion undergoing revascularization was similar (36.8% for non-ST-elevation vs. 41.9% ST-elevation MI, p = 0.277). In-hospital mortality also was similar in the two groups (62.5% for non-ST-elevation vs. 60.4% ST-elevation MI). After adjustment, ST-segment elevation MI did not independently predict in-hospital mortality (odds ratio, 1.30; 95% confidence interval, 0.83 to 2.02; p = 0.252). CONCLUSIONS: Patients with CS and non-ST-segment elevation MI have a higher-risk profile than shock patients with ST-segment elevation, but similar in-hospital mortality. More recurrent ischemia and less angiography represent opportunities for earlier intervention, and early reperfusion therapy for circumflex artery occlusion should be considered when non-ST-elevation MI causes CS
— id: 38021, year: 2000, vol: 36, page: 1091, stat: Journal Article,

Management of patients with acute coronary syndromes in the United States by platelet glycoprotein IIb/IIIa inhibition. Insights from the platelet glycoprotein IIb/IIIa in unstable angina: receptor suppression using integrilin therapy (PURSUIT) trial
Lincoff AM; Harrington RA; Califf RM; Hochman JS; Guerci AD; Ohman EM; Pepine CJ; Kopecky SL; Kleiman NS; Pacchiana CM; Berdan LG; Kitt MM; Simoons ML; Topol EJ
2000 Sep 5;102(10):1093-1100, Circulation
BACKGROUND: A multinational, randomized, placebo-controlled trial (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy, PURSUIT) demonstrated that the platelet glycoprotein IIb/IIIa receptor antagonist eptifibatide reduced the incidence of death or myocardial infarction among patients with acute ischemic syndromes without ST-segment elevation. Because of expected differences in practice patterns, a prospectively planned analysis of outcomes as a function of regions of the world was performed. The current study provides a detailed assessment of eptifibatide among the subgroup of patients enrolled within the United States. METHODS AND RESULTS: Patients presenting with chest pain within the previous 24 hours and ischemic ECG changes or creatine kinase-MB elevation were eligible for enrollment. Of the 10 948 patients randomized worldwide, 4035 were enrolled within the United States. Patients were allocated to placebo or eptifibatide infusion for up to 72 to 96 hours. Other medical therapies and revascularization strategies were at the discretion of the treating physician. Eptifibatide reduced the rate of the primary end point of death or myocardial infarction by 30 days from 15.4% to 11.9% (P=0.003) among patients in the United States. The treatment effect was achieved early and maintained over a period of 6 months (18.9% versus 15.2%; P=0.004). Bleeding events were more common in patients receiving eptifibatide but were predominantly associated with invasive procedures. The magnitude of clinical benefit from eptifibatide was greater among patients in the United States than elsewhere in the world. CONCLUSIONS: Platelet glycoprotein IIb/IIIa receptor blockade with eptifibatide reduces the incidence of death or myocardial infarction among patients treated for acute ischemic syndromes without ST-segment elevation within the United States
— id: 38942, year: 2000, vol: 102, page: 1093, stat: Journal Article,

Reference guide to cardiogenic shock complicating acute myocardial infarction
Menon V; Hochman JS
2000 Jan;9(1):95-98, Journal of thrombosis & thrombolysis
— id: 38946, year: 2000, vol: 9, page: 95, stat: Journal Article,

Lack of progress in cardiogenic shock: lessons from the GUSTO trials
Menon V; Hochman JS; Stebbins A; Pfisterer M; Col J; Anderson RD; Hasdai D; Holmes DR; Bates ER; Topol EJ; Califf RM; Ohman EM
2000 Dec;21(23):1928-1936, European heart journal
AIMS: We used the GUSTO-I and GUSTO-III databases to evaluate our performance in treating cardiogenic shock patients over much of the 1990s. METHODS AND RESULTS: GUSTO-I (1990-1993) and GUSTO-III (1995-1997) prospectively identified all patients with cardiogenic shock complicating acute myocardial infarction. Demographics, clinical presentation and outcomes for cardiogenic shock patients in the two trials were compared. Only patients enrolled with cardiogenic shock in countries common to both trials were included in these analysis. The 695 patients with cardiogenic shock in GUSTO-III were compared with the 2814 patients with cardiogenic shock in GUSTO-I. GUSTO-III patients were older (P=0.0001) and more likely to be diabetic (P=0.009) and hypertensive (P=0.025). They had a higher Killip class (P=0.002) and significantly greater index anterior infarction than cardiogenic shock patients enrolled in GUSTO-I. Time to treatment, presentation heart rate, and diastolic blood pressure were similar; however, systolic blood pressure at presentation was higher among GUSTO-III patients (P=0.002). Rates of coronary angiography, pulmonary artery catheterization, and mechanical ventilation declined in GUSTO-III compared with GUSTO-I (P=0.001); rates of angioplasty and bypass surgery were similar. Cardiogenic shock mortality in GUSTO-III was significantly higher than in GUSTO-I (62 vs 54%, P=0.001), as were rates of reinfarction (14 vs 11%, P=0.013) and recurrent ischaemia (35 vs 27%, P=0.00001). Mortality at non-U.S. sites (68 and 64%) was higher than at U.S. sites (53 and 50%) in both GUSTO-I and GUSTO-III studies, respectively. Angioplasty, bypass surgery, and balloon pump rates were lower for non-U.S. patients. CONCLUSIONS: Cardiogenic shock continues to be associated with high mortality in thrombolytic-treated patients. Lower mortality observed in the U.S.A. supports consideration for percutaneous and surgical revascularization
— id: 38929, year: 2000, vol: 21, page: 1928, stat: Journal Article,

Acute myocardial infarction complicated by systemic hypoperfusion without hypotension: report of the SHOCK trial registry
Menon V; Slater JN; White HD; Sleeper LA; Cocke T; Hochman JS
2000 Apr 1;108(5):374-380, American journal of medicine
BACKGROUND: Cardiogenic shock is usually characterized by inadequate cardiac output and sustained hypotension. However, following a large myocardial infarction, peripheral hypoperfusion can occur with relatively well maintained systolic blood pressure, a condition known as nonhypotensive cardiogenic shock. The aim of this study was to determine the characteristics of patients with this condition. METHODS: The SHOCK trial registry prospectively enrolled patients with suspected cardiogenic shock complicating acute myocardial infarction. We identified a group of 49 patients who presented with nonhypotensive shock, defined as clinical evidence of peripheral hypoperfusion with a systolic blood pressure >90 mm Hg without vasopressor circulatory support. Clinical characteristics, hemodynamic data, and outcomes in these patients were compared with a group of 943 patients with classic cardiogenic shock with hypotension. The age, gender, and distributions of coronary risk factors were similar in both groups. RESULTS: Patients with nonhypotensive shock were more likely to have an anterior wall myocardial infarction (71% versus 53%, P = 0.03). Both groups of patients had similar rates of treatment with thrombolytic therapy, angioplasty, and bypass surgery. Patients with nonhypotensive shock had an in-hospital mortality rate of 43% as compared with a rate of 66% among patients who had classic cardiogenic shock with hypotension (P = 0.001). Mortality among 76 patients who presented with a systolic blood pressure <90 mm Hg but no hypoperfusion was 26%. CONCLUSIONS: Even in the presence of normal blood pressure, clinical signs of peripheral hypoperfusion, which may be subtle, are associated with a substantial risk of in-hospital death following acute myocardial infarction
— id: 38022, year: 2000, vol: 108, page: 374, stat: Journal Article,

Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?
Menon V; Webb JG; Hillis LD; Sleeper LA; Abboud R; Dzavik V; Slater JN; Forman R; Monrad ES; Talley JD; Hochman JS
2000 Sep;36(3 Suppl A):1110-1116, Journal of the American College of Cardiology
OBJECTIVES: We wished to assess the profile and outcomes of patients with ventricular septal rupture (VSR) in the setting of cardiogenic shock (CS) complicating acute myocardial infarction (MI). BACKGROUND: Cardiogenic shock is often seen with VSR complicating acute MI. Despite surgical therapy, mortality in such patients is high. METHODS: We analyzed 939 patients enrolled in the SHOCK Trial Registry of CS in acute infarction, comparing 55 patients whose shock was associated with VSR with 884 patients who had predominant left ventricular failure. RESULTS: Rupture occurred a median 16 h after infarction. Patients with VSR tended to be older (p = 0.053), were more often female (p = 0.002) and less often had previous infarction (p < 0.001), diabetes mellitus (p = 0.015) or smoking history (p = 0.033). They also underwent right-heart catheterization, intra-aortic balloon pumping and bypass surgery significantly more often. Although patients with rupture had less severe coronary disease, their in-hospital mortality was higher (87% vs. 61%, p < 0.001). Surgical repair was performed in 31 patients with rupture (21 had concomitant bypass surgery); 6 (19%) survived. Of the 24 patients managed medically, only 1 survived. CONCLUSIONS: There is a high in-hospital mortality rate when CS develops as a result of VSR. Ventricular septal rupture may occur early after infarction, and women and the elderly may be more susceptible. Although the prognosis is poor, surgery remains the best therapeutic option in this setting
— id: 38020, year: 2000, vol: 36, page: 1110, stat: Journal Article,

The clinical profile of patients with suspected cardiogenic shock due to predominant left ventricular failure: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?
Menon V; White H; LeJemtel T; Webb JG; Sleeper LA; Hochman JS
2000 Sep;36(3 Suppl A):1071-1076, Journal of the American College of Cardiology
OBJECTIVES: We sought to evaluate the frequency of pulmonary congestion and associated clinical and hemodynamic findings in patients with suspected cardiogenic shock (CS). BACKGROUND: The prevalence of pulmonary congestion in the setting of CS is uncertain. METHODS: The 571 SHOCK Trial Registry patients with predominant left ventricular failure (LVF) were divided into four groups: Group A = no pulmonary congestion/no hypoperfusion = 14 (3%), Group B = isolated pulmonary congestion = 32 (6%), Group C = isolated hypoperfusion = 158 (28%) and Group D = congestion with hypoperfusion = 367 (64%). Statistical comparisons between Group C and D only, with regard to patient demographics, hemodynamics, treatment and outcome, were made. RESULTS: A significant proportion of patients with shock had no pulmonary congestion (Group C = 28%, 95% CI, 24% to 31%). Age and gender in this group were similar to Group D. Group C patients were less likely to have a prior MI (p = 0.028), congestive heart failure (p = 0.005) and renal insufficiency (p = 0.032), and the index MI was less likely to be anterior (p = 0.044). Cardiac output, cardiac index and ejection fraction were similar for the two groups but pulmonary capillary wedge pressure was slightly lower for Group C (22 vs. 24 mm Hg, p = 0.012). Treatment with thrombolysis, angioplasty and bypass surgery was similar in the two groups. In-hospital mortality rates for Groups C and D were 70% and 60%, respectively (p = 0.036). After adjustment, this difference was no longer statistically significant (p = 0.153). CONCLUSIONS: Absence of pulmonary congestion at initial clinical evaluation does not exclude a diagnosis of CS due to predominant LVF and is not associated with a better prognosis
— id: 38939, year: 2000, vol: 36, page: 1071, stat: Journal Article,

American College of Cardiology/American Heart Association Expert Consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease
O'Rourke RA; Brundage BH; Froelicher VF; Greenland P; Grundy SM; Hachamovitch R; Pohost GM; Shaw LJ; Weintraub WS; Winters WL Jr; Forrester JS; Douglas PS; Faxon DP; Fisher JD; Gregoratos G; Hochman JS; Hutter AM Jr; Kaul S; Wolk MJ
2000 Jul 4;102(1):126-140, Circulation
— id: 38943, year: 2000, vol: 102, page: 126, stat: Journal Article,

Successful repair of myocardial free wall rupture after thrombolytic therapy for acute infarction
Park WM; Connery CP; Hochman JS; Tilson MD; Anagnostopoulos CE
2000 Oct;70(4):1345-1349, Annals of thoracic surgery
BACKGROUND: Controversy exists regarding the timing of thrombolytic administration and rupture rate. METHODS: Hospital records at St. Luke's-Roosevelt Hospital of the 4 study patients were reviewed and compared with those of 41 patients from a group of 537 patients concurrently admitted with a diagnosis of myocardial infarction (MI). RESULTS: Four patients experienced ventricular free wall rupture after having a MI between November 17, 1993, and July 28, 1995. All received tissue plasminogen activator. In 1 patient, pericardial effusion associated with a pseudoaneurysm was discovered in the operating room. The 3 others developed clinical pericardial tamponade before surgery. All 4 patients survived and left the hospital on postoperative days 10, 11, 11, and 82, respectively. During this same time period, 537 patients were admitted with MI, 41 of whom died; the study's 4 patients were compared with these 41. CONCLUSIONS: These data demonstrate that rupture of the ventricular free wall can occur early after thrombolytic therapy and may have a subacute course. Prompt diagnosis and surgery offer excellent chances of surviving this fatal condition
— id: 43527, year: 2000, vol: 70, page: 1345, stat: Journal Article,

Early reperfusion, late reperfusion, and the open artery hypothesis: an overview
Sadanandan S; Hochman JS
2000 May-Jun;42(6):397-404, Progress in cardiovascular diseases
Randomized clinical trials have clearly shown the beneficial effects of early reperfusion within 12 hours, and possibly up to 24 hours, after acute myocardial infarction (AMI). The data on late reperfusion beyond 24 hours are less convincing. Many studies show that an open infarct-related artery after MI, irrespective of the initial reperfusion strategy, is independently associated with improved long-term clinical outcome. However, similar analysis of the large Global Utilization of Streptokinase and tPA for Occluded Arteries (GUSTO) 1 study did not confirm this finding. It is unclear whether mechanical reperfusion of an occluded infarct-related artery late after MI (>24 hours) in asymptomatic patients will confer long-term benefits. The late open artery hypothesis, which proposes several mechanisms by which late reperfusion may offer benefit, remains to be tested in a large clinical trial. This overview focuses on the definitions of early reperfusion, late reperfusion, the relationship between timing of reperfusion and prognosis after AMI, and the late open artery hypothesis
— id: 38944, year: 2000, vol: 42, page: 397, stat: Journal Article,

Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?
Sanborn TA; Sleeper LA; Bates ER; Jacobs AK; Boland J; French JK; Dens J; Dzavik V; Palmeri ST; Webb JG; Goldberger M; Hochman JS
2000 Sep;36(3 Suppl A):1123-1129, Journal of the American College of Cardiology
OBJECTIVES: We sought to investigate the potential benefit of thrombolytic therapy (TT) and intra-aortic balloon pump counterpulsation (IABP) on in-hospital mortality rates of patients enrolled in a prospective, multi-center Registry of acute myocardial infarction (MI) complicated by cardiogenic shock (CS). BACKGROUND: Retrospective studies suggest that patients suffering from CS due to MI have lower in-hospital mortality rates when IABP support is added to TT. This hypothesis has not heretofore been examined prospectively in a study devoted to CS. METHODS: Of 1,190 patients enrolled at 36 participating centers, 884 patients had CS due to predominant left ventricular (LV) failure. Excluding 26 patients with IABP placed prior to shock onset and 2 patients with incomplete data, 856 patients were evaluated regarding TT and IABP utilization. Treatments, selected by local physicians, fell into four categories: no TT, no IABP (33%; n = 285); IABP only (33%; n = 279); TT only (15%; n = 132); and TT and IABP (19%; n = 160). RESULTS: Patients in CS treated with TT had a lower in-hospital mortality than those who did not receive TT (54% vs. 64%, p = 0.005), and those selected for IABP had a lower in-hospital mortality than those who did not receive IABP (50% vs. 72%, p < 0.0001). Furthermore, there was a significant difference in in-hospital mortality among the four treatment groups: TT + IABP (47%), IABP only (52%), TT only (63%), no TT, no IABP (77%) (p < 0.0001). Patients receiving early IABP (< or = 6 h after thrombolytic therapy, n = 72) had in-hospital mortality similar to those with late IABP (53% vs. 41%, n = 64, respectively, p = 0.172). Revascularization rates differed among the four groups: no TT, no IABP (18%); IABP only (70%); TT only (20%); TT and IABP (68%, p < 0.0001); this influenced in-hospital mortality significantly (39% with revascularization vs. 78% without revascularization, p < 0.0001). CONCLUSIONS: Treatment of patients in cardiogenic shock due to predominant LV failure with TT, IABP and revascularization by PTCA/CABG was associated with lower in-hospital mortality rates than standard medical therapy in this Registry. For hospitals without revascularization capability, a strategy of early TT and IABP followed by immediate transfer for PTCA or CABG may be appropriate. However, selection bias is evident and further investigation is required
— id: 38933, year: 2000, vol: 36, page: 1123, stat: Journal Article,

Diabetes mellitus in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?
Shindler DM; Palmeri ST; Antonelli TA; Sleeper LA; Boland J; Cocke TP; Hochman JS
2000 Sep;36(3 Suppl A):1097-1103, Journal of the American College of Cardiology
OBJECTIVES: We sought to examine the role of diabetes mellitus in cardiogenic shock (CS) complicating acute myocardial infarction (AMI) in the SHOCK Trial Registry. BACKGROUND: The characteristics, outcomes and optimal treatment of diabetic patients with CS complicating AMI have not been well described. METHODS: Baseline characteristics, clinical and hemodynamic measures, treatment variables, shock etiologies and comorbid conditions were compared for 379 diabetic and 784 nondiabetic patients. Logistic regression was used to examine the association between diabetes and in-hospital mortality, after adjustment for baseline differences. RESULTS: Diabetics were less likely than nondiabetics to undergo thrombolysis (28% vs. 37%; p = 0.002) or attempted revascularization (40% vs. 49%; p = 0.008). The survival benefit for diabetics selected for percutaneous or surgical revascularization (55% vs. 19% without revascularization) was similar to that for nondiabetics (59% vs. 25%). Overall unadjusted in-hospital mortality was significantly higher for diabetics (67% vs. 58%; p = 0.007), but diabetes was only a borderline predictor of mortality after adjustment for baseline and treatment differences (odds ratio for death, 1.36; 95% confidence interval, 1.00 to 1.84; p = 0.051). CONCLUSIONS: Diabetics with CS complicating AMI have a higher-risk profile at baseline, but after adjustment, diabetics have an in-hospital survival rate that is only marginally lower than that of nondiabetics. Diabetics who undergo revascularization derive a survival benefit similar to that of nondiabetics
— id: 38936, year: 2000, vol: 36, page: 1097, stat: Journal Article,

Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?
Slater J; Brown RJ; Antonelli TA; Menon V; Boland J; Col J; Dzavik V; Greenberg M; Menegus M; Connery C; Hochman JS
2000 Sep;36(3 Suppl A):1117-1122, Journal of the American College of Cardiology
OBJECTIVES: We sought to compare the characteristics and outcomes of patients with acute myocardial infarction (MI) and cardiogenic shock (CS) caused by rupture of the ventricular free wall or tamponade versus shock from other causes. BACKGROUND: Free-wall rupture is a recognized cause of mortality in patients with acute MI. Some of these patients present subacutely, which provides an opportunity for intervention. Recognition of factors that distinguish them from the overall shock cohort would be beneficial. METHODS: The international SHOCK Trial Registry enrolled patients concurrently with the randomized SHOCK Trial. Thirty-six centers consecutively enrolled all patients with suspected CS after MI, regardless of trial eligibility. RESULTS: Of the 1,048 patients studied, 28 (2.7%) had free-wall rupture or tamponade. These patients had less pulmonary edema, less diabetes, less prior MI, and less prior congestive heart failure (all p < 0.05). They more often had new Q waves in two or more leads (51.9% vs. 31.5%, p < 0.04), but MI location and time to shock onset after MI did not differ. Of patients with rupture or tamponade, 75% had pericardial effusions. No hemodynamic characteristics identified patients with rupture/tamponade. Most patients with rupture/tamponade had surgery and/or pericardiocentesis (27/28); their in-hospital survival rate was identical to that of the group overall (39.3%). Women and older patients with rupture/tamponade tended to survive intervention less often. CONCLUSIONS: Free-wall rupture and tamponade may present as CS after MI, and survival after intervention is similar to that of the overall shock cohort. All patients with CS after MI should have echocardiography in order to detect subacute rupture or tamponade and initiate appropriate interventions
— id: 38934, year: 2000, vol: 36, page: 1117, stat: Journal Article,

Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we use emergently revascularize Occluded Coronaries in cardiogenic shocK?
Thompson CR; Buller CE; Sleeper LA; Antonelli TA; Webb JG; Jaber WA; Abel JG; Hochman JS
2000 Sep;36(3 Suppl A):1104-1109, Journal of the American College of Cardiology
OBJECTIVES: Our objective was to define the outcomes of patients with cardiogenic shock (CS) due to severe mitral regurgitation (MR) complicating acute myocardial infarction (AMI). BACKGROUND: Methods for early identification and optimal treatment of such patients have not been defined. METHODS: The SHOCK Trial Registry enrolled 1,190 patients with CS complicating AMI. We compared 1) the cohort with severe mitral regurgitation (MR, n = 98) to the cohort with predominant left ventricular failure (LVF, n = 879), and 2) the MR patients who underwent valve surgery (n = 43) to those who did not (n = 51). RESULTS: Shock developed early after MI in both the MR (median 12.8 h) and LVF (median 6.2 h) cohorts. The MR patients were more often female (52% vs. 37%, p = 0.004) and less likely to have ST elevation at shock diagnosis (41% vs. 63%, p < 0.001). The MR index MI was more frequently inferior (55% vs. 44%, p = 0.039) or posterior (32% vs. 17%, p = 0.002) than that of LVF and much less frequently anterior (34% vs. 59%, p < 0.001). Despite having higher mean LVEF (0.37 vs. 0.30, p = 0.001) the MR cohort had similar in-hospital mortality (55% vs. 61%, p = 0.277). The majority of MR patients did not undergo mitral valve surgery. Those undergoing surgery exhibited higher mean LVEF than those not undergoing surgery; nevertheless, 39% died in hospital. CONCLUSIONS: The data highlight opportunities for early identification and intervention to potentially decrease the devastating mortality and morbidity of severe post-myocardial infarction MR
— id: 38935, year: 2000, vol: 36, page: 1104, stat: Journal Article,

Survival outcomes 1 year after reperfusion therapy with either alteplase or reteplase for acute myocardial infarction: results from the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) III Trial
Topol EJ; Ohman EM; Armstrong PW; Wilcox R; Skene AM; Aylward P; Simes J; Dalby A; Betriu A; Bode C; White HD; Hochman JS; Emanuelson H; Vahanian A; Sapp S; Stebbins A; Moliterno DJ; Califf RM
2000 Oct 10;102(15):1761-1765, Circulation
BACKGROUND: New recombinant plasminogen activators have been developed to simulate the fibrinolytic action of the physiological serine protease tissue plasminogen activator (alteplase, t-PA), and have prolonged half-life features permitting bolus administration. One such activator, reteplase (r-PA), was compared with t-PA in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-III Trial. METHODS AND RESULTS: At 1-year follow-up, survival status was ascertained in 97.4% of the 15 059 patients enrolled in the GUSTO-III trial. At 1 year, the mortality rate for the t-PA-assigned group was 11.06%, and for r-PA it was 11.20% (P:=0. 77). The absolute mortality difference of 0.14% has 95% CIs of -1. 21% to 0.93%. There were no significant differences in outcome by intention-to-treat for the 2 different plasminogen activators in the prespecified groups (age, infarct location, time-to-treatment). The absolute difference in mortality rates between t-PA and r-PA progressively narrowed over the predetermined observation times after random assignment; it was 0.31% at 24 hours, 0.26% at 7 days, 0.23% at 30 days, and 0.14% at 1 year. Of note, mortality rate in the trial between 30 days and 1 year in 13 883 patients was 4.02% and did not differ between the treatment groups. However, this mortality rate was substantially greater than in GUSTO-I, in which mortality rate for t-PA versus streptokinase between 30 days and 1-year was 2.97% (heart rate 1.36, 95% CI 1.23, 1.50, P:<0.001). CONCLUSIONS: The r-PA and t-PA strategies yielded similar survival outcomes after 30 days in this trial. The increase in mortality rate during extended follow-up compared with previous trials may reflect higher-risk patients and highlights the need for improved secondary prevention strategies
— id: 38930, year: 2000, vol: 102, page: 1761, stat: Journal Article,

Implications of the timing of onset of cardiogenic shock after acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?
Webb JG; Sleeper LA; Buller CE; Boland J; Palazzo A; Buller E; White HD; Hochman JS
2000 Sep;36(3 Suppl A):1084-1090, Journal of the American College of Cardiology
OBJECTIVES: We sought to examine the implications of the timing of onset of cardiogenic shock (CS) after acute myocardial infarction (MI). BACKGROUND: Little information is available about the relationships between timing, clinical substrate, management and outcomes of shock. METHODS: The multinational SHOCK Trial Registry enrolled MI patients with CS from 1993 to 1997. Cardiogenic shock was predominantly attributable to left ventricular (LV) failure in 815 Registry patients for whom temporal data were available. We examined factors related to the timing of shock onset and the relation of temporal onset to in-hospital outcomes. RESULTS: Overall, shock developed a median of 6.2 h after MI symptom onset. Shock onset varied by culprit artery: left main, median 1.7 h; right, 3.5 h; circumflex, 3.9 h; left anterior descending (LAD), 11.0 h; saphenous vein graft, 10.9 h (p = 0.025). Early shock (< 24 h) occurred in 74.1% and was associated with chest pain at shock onset, ST-segment elevation in two or more leads, multiple infarct locations, inferior MI, left main disease and smoking. Late shock (> or = 24 h) was associated with recurrent ischemia, Q waves in two or more leads and LAD culprit vessel. Mortality was higher in patients with early versus late shock (62.6% vs. 53.6%, p = 0.022). CONCLUSIONS: Shock onset after acute MI occurred within 24 h in 74% of the patients with predominant LV failure. Mortality was slightly higher in patients developing shock early rather than later. Many factors influence when shock develops, which has implications for its management
— id: 38937, year: 2000, vol: 36, page: 1084, stat: Journal Article,

Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?
Wong SC; Sanborn T; Sleeper LA; Webb JG; Pilchik R; Hart D; Mejnartowicz S; Antonelli TA; Lange R; French JK; Bergman G; LeJemtel T; Hochman JS
2000 Sep;36(3 Suppl A):1077-1083, Journal of the American College of Cardiology
OBJECTIVES: We sought to delineate the angiographic findings, clinical correlates and in-hospital outcomes in patients with cardiogenic shock (CS) complicating acute myocardial infarction. BACKGROUND: Patients with CS complicating acute myocardial infarction carry a grave prognosis. Detailed angiographic findings in a large, prospectively identified cohort of patients with CS are currently lacking. METHODS: We compared the clinical characteristics, angiographic findings, and in-hospital outcomes of 717 patients selected to undergo angiography and 442 not selected, overall and by shock etiology: left or right ventricular failure versus mechanical complications. RESULTS: Patients who underwent angiography had lower baseline risk and a better hemodynamic profile than those who did not. Overall, 15.5% of the patients had significant left main lesions on angiography, and 53.4% had three-vessel disease, with higher rates of both for those with ventricular failure, compared with patients who had mechanical complications. Among patients who underwent angiography, those with ventricular failure had significantly lower in-hospital mortality than patients with mechanical complications (45.2% vs. 57.0%; p = 0.021). Importantly, for patients with ventricular failure, in-hospital mortality also correlated with disease severity: 35.0% for no or single-vessel disease versus 50.8% for three-vessel disease. Furthermore, mortality was associated with the culprit lesion location (78.6% in left main lesion, 69.7% in saphenous vein graft lesions, 42.4% in circumflex lesions, 42.3% in left anterior descending lesions, and 37.4% in right coronary artery lesions), and Thrombolysis In Myocardial Infarction (TIMI) flow grade (46.5% in TIMI 0/1, 49.4% in TIMI 2 and 26% in TIMI 3). CONCLUSIONS: Patients who underwent angiographic study in the SHOCK Trial Registry had a more benign cardiac risk profile, more favorable hemodynamic findings and lower in-hospital mortality than those for whom angiograms were not obtained. Patients with CS caused by ventricular failure had more severe atherosclerosis, and a different distribution of culprit vessel involvement but lower in-hospital mortality, than those with mechanical complications. Overall in-hospital survival correlates with the extent of coronary artery obstructions, location of culprit lesion and baseline coronary TIMI flow grade
— id: 38938, year: 2000, vol: 36, page: 1077, stat: Journal Article,

Prior aspirin use predicts worse outcomes in patients with non-ST-elevation acute coronary syndromes. PURSUIT Investigators. Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy
Alexander JH; Harrington RA; Tuttle RH; Berdan LG; Lincoff AM; Deckers JW; Simoons ML; Guerci A; Hochman JS; Wilcox RG; Kitt MM; Eisenberg PR; Califf RM; Topol EJ; Karsh K; Ruzyllo W; Stepinska J; Widimsky P; Boland JB; Armstrong PW
1999 Apr 15;83(8):1147-1151, American journal of cardiology
Aspirin is beneficial in the prevention and treatment of cardiovascular events, but patients who have events while taking aspirin may have worse outcomes than those not on aspirin. We investigated the association between prior aspirin use and clinical outcomes in 9,461 patients with non-ST-elevation acute coronary syndromes enrolled in the Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, before and after adjustment for baseline factors. We also examined whether eptifibatide has a differential treatment effect in prior aspirin users. Prior aspirin users were less likely to have an enrollment myocardial infarction (MI) (vs unstable angina) (43.9% vs 48.8%, p = 0.001) but more likely to have death or MI at 30 days (16.1% vs 13.0%, p = 0.001) and at 6 months (19.9% vs 15.9%, p = 0.001). After adjustment, prior aspirin users remained less likely to have an enrollment MI (odds ratio 0.88, 95% confidence interval 0.79 to 0.97) and more likely to have death or MI at 30 days (odds ratio 1.16, 95% confidence interval 1.00 to 1.33) but not at 6 months (odds ratio 1.14, 95% confidence interval 0.98 to 1.33). In a multivariable model, eptifibatide did not have a different treatment effect in prior aspirin users compared with nonusers (p = 0.534). Prior aspirin users had fewer enrollment MIs but worse long-term outcomes than nonusers. We found no evidence for a different treatment effect of eptifibatide in prior aspirin users
— id: 38951, year: 1999, vol: 83, page: 1147, stat: Journal Article,

Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists: observations from the Thrombolysis and Thrombin Inhibition in Myocardial Infarction 9 Study
Becker RC; Hochman JS; Cannon CP; Spencer FA; Ball SP; Rizzo MJ; Antman EM
1999 Feb;33(2):479-487, Journal of the American College of Cardiology
OBJECTIVES: The purpose of this study was to determine the incidence and demographic characteristics of patients experiencing cardiac rupture after thrombolytic and adjunctive anticoagulant therapy and to identify possible associations between the mechanism of thrombin inhibition (indirect, direct) and the intensity of systemic anticoagulation with its occurrence. BACKGROUND Cardiac rupture is responsible for nearly 15% of all in-hospital deaths among patients with myocardial infarction (MI) given thrombolytic agents. Little is known about specific patient- and treatment-related risk factors. METHODS Patients (n = 3,759) with MI participating in the Thrombolysis and Thrombin Inhibition in Myocardial Infarction 9A and B trials received intravenous thrombolytic therapy, aspirin and either heparin (5,000 U bolus, 1,000 to 1,300 U/h infusion) or hirudin (0.1 to 0.6 mg/kg bolus, 0.1 to 0.2 mg/kg/h infusion) for at least 96 h. A diagnosis of cardiac rupture was made clinically in patients with sudden electromechanical dissociation in the absence of preceding congestive heart failure, slowly progressive hemodynamic compromise or malignant ventricular arrhythmias. RESULTS A total of 65 rupture events (1.7%) were reported-all were fatal, and a majority occurred within 48 h of treatment Patients with cardiac rupture were older, of lower body weight and stature and more likely to be female than those without rupture (all p < 0.001). By multivariable analysis, age >70 years (odds ratio [OR] 3.77; 95% confidence interval [CI] 2.06, 6.91), female gender (OR 2.87; 95% CI 1.44, 5.73) and prior angina (OR 1.82; 95% CI 1.05, 3.16) were independently associated with cardiac rupture. Independent predictors of nonrupture death included age >70 years (OR 3.68; 95% CI 2.53, 5.35) and prior MI (OR 2.14; 95%, CI 1.45, 3.17). There was no association between the type of thrombin inhibition, the intensity of anticoagulation and cardiac rapture. CONCLUSIONS Cardiac rupture following thrombolytic therapy tends to occur in older patients and may explain the disproportionately high mortality rate among women in prior dinical trials. Unlike major hemorrhagic complications, there is no evidence that the intensity of anticoagulation associated with heparin or hirudin administration influences the occurrence of rupture
— id: 38953, year: 1999, vol: 33, page: 479, stat: Journal Article,

Relation between infarct artery patency at late angiography after acute myocardial infarction and signal-averaged electrocardiography
Chandrasekaran S; Hochman JS; Slater JN; Palazzo AM; Morgan CD; Steinberg JS
1999 Sep 15;84(6):734-6, A8, American journal of cardiology
The angiograms of 89 patients were reviewed from the LATE Ancillary Study (randomized trial of recombinant tissue plasminogen activator vs placebo in patients with symptom onset after 6 hours of myocardial infarction) to determine patency of the infarct-related artery (IRA). In the occluded IRA group (n = 35), the incidence of signal-averaged electrocardiographic abnormality (fQRS > 120 ms) was significantly higher (p = 0.04), the filtered QRS duration was significantly longer (p = 0.007), and the V40 was significantly shorter (p = 0.02), compared with the patent IRA group (n = 54)
— id: 38023, year: 1999, vol: 84, page: 734, stat: Journal Article,

Cardiogenic shock complicating acute myocardial infarction: predictors of death. GUSTO Investigators. Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries
Hasdai D; Holmes DR Jr; Califf RM; Thompson TD; Hochman JS; Pfisterer M; Topol EJ
1999 Jul;138(1 Pt 1):21-31, American heart journal
BACKGROUND: Current knowledge of predictors of death among patients with cardiogenic shock complicating myocardial infarction is limited. We aimed to develop a risk assessment prognostic algorithm of 30-day mortality, including clinical and hemodynamic data prospectively collected among patients with cardiogenic shock in the 41,021-patient Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial. METHODS: We used logistic regression modeling techniques to evaluate the relations between demographic, clinical, and hemodynamic characteristics and 30-day mortality rate for the entire shock population (n = 2968) and for patients who underwent right-heart catheterization (n = 995). RESULTS: The odds (95% confidence interval) of dying were 1.49 times higher (1.27-1.74) for patients 10 years older and 1.70 times higher (1.19-2.44) for patients with prior infarction. Findings derived from physical examination, such as altered sensorium and cold, clammy skin, were important independent predictors of prognosis (odds of dying 1.68 times higher for each [1.19-2.39 and 1.15-2.46]). The odds of dying were also 2.25 times higher (1.61-3.15) in patients with oliguria. Mortality rate was lowest for cardiac output and pulmonary capillary wedge measurements of 5.1 L/min and 20 mm Hg, respectively, and increased with either higher or lower values. Patients with shock had better outcomes than patients in whom shock developed later, although for the latter subgroup, prognosis was worse in patients who had heart failure (Killip class II to III). CONCLUSIONS: We devised a prognostic algorithm for patients with cardiogenic shock complicating acute myocardial infarction. In addition to demographic and easily derived physical examination features, data derived from right-heart catheterization added valuable information that increased the ability to predict outcome in this high-risk population
— id: 38950, year: 1999, vol: 138, page: 21, stat: Journal Article,

Frequency and clinical outcome of cardiogenic shock during acute myocardial infarction among patients receiving reteplase or alteplase. Results from GUSTO-III. Global Use of Strategies to Open Occluded Coronary Arteries
Hasdai D; Holmes DR Jr; Topol EJ; Berger PB; Criger DA; Hochman JS; Bates ER; Vahanian A; Armstrong PW; Wilcox R; Ohman EM; Califf RM
1999 Jan;20(2):128-135, European heart journal
AIMS: Reteplase has been reported to achieve better patency of the infarct artery than alteplase. As infarct artery patency is strongly associated with survival among patients with cardiogenic shock, we postulated that treatment with reteplase would improve outcomes among shock patients. METHODS: We compared 30-day mortality rates among patients in GUSTO-III who either presented with shock or developed shock after enrollment; all patients received either front-loaded alteplase or reteplase (two bolus doses of 10 MU, 30 min apart). RESULTS: Shock occurred in 260 (5.3%) of 4921 patients randomized to alteplase and 560 (5.5%) of 10,138 patients randomized to reteplase. Of these patients, 28 (10.8%) and 55 (9.8%) randomized to alteplase and reteplase, respectively, presented with shock. In-hospital, 35% and 37% of shock patients assigned to alteplase or reteplase, respectively, underwent coronary angiography, with similar rates of percutaneous (approximately 11-13%) or surgical (approximately 2-3%) revascularization procedures subsequently performed. Death within 30 days occurred in 169 (65%) and 353 (63%) shock patients randomized to alteplase and reteplase, respectively (P = 0.59). Of patients presenting with shock, 64% and 58% of patients randomized to alteplase or reteplase died within 30 days (P = 0.59). CONCLUSION: Compared with alteplase, reteplase did not improve outcome among patients who presented with shock or developed shock after receiving thrombolytics. The newer-generation thrombolytic agents remain of limited efficacy in the treatment and prevention of shock
— id: 38952, year: 1999, vol: 20, page: 128, stat: Journal Article,

SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK: an international randomized trial of emergency PTCA/CABG-trial design. The SHOCK Trial Study Group
Hochman JS; Sleeper LA; Godfrey E; McKinlay SM; Sanborn T; Col J; LeJemtel T
1999 Feb;137(2):313-321, American heart journal
BACKGROUND: Cardiogenic shock (CS) is the leading cause of death in patients hospitalized with acute myocardial infarction (MI). Nonrandomized studies suggest reduced mortality rate with revascularization. TRIAL DESIGN: The SHOCK trial is a multicenter, randomized, and unblinded study with a Registry for trial-eligible and ineligible nonrandomized patients. The trial is testing the hypothesis that a direct invasive strategy of emergency revascularization for patients with cardiogenic shock complicating acute MI will reduce 30-day all-cause mortality rate by 20 absolute percentage points compared with initial medical stabilization. Eligibility criteria include development of CS within 36 hours of an acute transmural MI as evidenced by ST elevation or new left bundle branch block MI; clinical criteria for CS with hemodynamic confirmation; absence of a mechanical, iatrogenic, or other cause of shock; and enrollment within 12 hours of CS diagnosis. Patients randomly assigned to emergency revascularization immediately undergo coronary angiography, with percutaneous transluminal coronary angioplasty or coronary artery bypass grafting depending on the coronary anatomy. Patients assigned to initial medical stabilization may undergo revascularization >/=54 hours after randomization. END POINTS: The primary end point is all-cause 30-day mortality after randomization. Secondary end points include death at trial termination, changes in left ventricular dimensions and function measured by echocardiography at randomization and 2 weeks later, and changes in quality of life and physical functioning from 2 weeks after discharge to 6 months after MI
— id: 38954, year: 1999, vol: 137, page: 313, stat: Journal Article,

Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock
Hochman JS; Sleeper LA; Webb JG; Sanborn TA; White HD; Talley JD; Buller CE; Jacobs AK; Slater JN; Col J; McKinlay SM; LeJemtel TH
1999 Aug 26;341(9):625-634, New England journal of medicine
BACKGROUND: The leading cause of death in patients hospitalized for acute myocardial infarction is cardiogenic shock. We conducted a randomized trial to evaluate early revascularization in patients with cardiogenic shock. METHODS: Patients with shock due to left ventricular failure complicating myocardial infarction were randomly assigned to emergency revascularization (152 patients) or initial medical stabilization (150 patients). Revascularization was accomplished by either coronary-artery bypass grafting or angioplasty. Intraaortic balloon counterpulsation was performed in 86 percent of the patients in both groups. The primary end point was mortality from all causes at 30 days. Six-month survival was a secondary end point. RESULTS: The mean age of the patients was 66+/-10 years, 32 percent were women and 55 percent were transferred from other hospitals. The median time to the onset of shock was 5.6 hours after infarction, and most infarcts were anterior in location. Ninety-seven percent of the patients assigned to revascularization underwent early coronary angiography, and 87 percent underwent revascularization; only 2.7 percent of the patients assigned to medical therapy crossed over to early revascularization without clinical indication. Overall mortality at 30 days did not differ significantly between the revascularization and medical-therapy groups (46.7 percent and 56.0 percent, respectively; difference, -9.3 percent; 95 percent confidence interval for the difference, -20.5 to 1.9 percent; P=0.11). Six-month mortality was lower in the revascularization group than in the medical-therapy group (50.3 percent vs. 63.1 percent, P=0.027). CONCLUSIONS: In patients with cardiogenic shock, emergency revascularization did not significantly reduce overall mortality at 30 days. However, after six months there was a significant survival benefit. Early revascularization should be strongly considered for patients with acute myocardial infarction complicated by cardiogenic shock
— id: 38024, year: 1999, vol: 341, page: 625, stat: Journal Article,

Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators
Hochman JS; Tamis JE; Thompson TD; Weaver WD; White HD; Van de Werf F; Aylward P; Topol EJ; Califf RM
1999 Jul 22;341(4):226-232, New England journal of medicine
BACKGROUND: Studies have reported that women with acute myocardial infarction have in-hospital and long-term outcomes that are worse than those of men. METHODS: To assess sex-based differences in presentation and outcome, we examined data from the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb study, which enrolled 12,142 patients (3662 women and 8480 men) with acute coronary syndromes, including infarction with ST-segment elevation, infarction with no ST-segment elevation, and unstable angina. RESULTS: Overall, the women were older than the men, and had significantly higher rates of diabetes, hypertension, and prior congestive heart failure. They had significantly lower rates of prior myocardial infarction and were less likely ever to have smoked. A smaller percentage of women than men had infarction with ST elevation (27.2 percent vs. 37.0 percent, P<0.001), and of the patients who presented with no ST elevation (those with myocardial infarction or unstable angina), fewer women than men had myocardial infarction (36.6 percent vs. 47.6 percent, P<0.001). Women had more complications than men during hospitalization and a higher mortality rate at 30 days (6.0 percent vs. 4.0 percent, P<0.001) but had similar rates of reinfarction at 30 days after presentation. However, there was a significant interaction between sex and the type of coronary syndrome at presentation (P=0.001). After stratification according to coronary syndrome and adjustment for base-line variables, there was a nonsignificant trend toward an increased risk of death or reinfarction among women as compared with men only in the group with infarction and ST elevation (odds ratio, 1.27; 95 percent confidence interval, 0.98 to 1.63; P=0.07). Among patients with unstable angina, female sex was associated with an independent protective effect (odds ratio for infarction or death, 0.65; 95 percent confidence interval, 0.49 to 0.87; P=0.003). CONCLUSIONS: Women and men with acute coronary syndromes had different clinical profiles, presentation, and outcomes. These differences could not be entirely accounted for by differences in base-line characteristics and may reflect pathophysiologic and anatomical differences between men and women
— id: 38949, year: 1999, vol: 341, page: 226, stat: Journal Article,

A new regimen for heparin use in acute coronary syndromes
Hochman JS; Wali AU; Gavrila D; Sim MJ; Malhotra S; Palazzo AM; De La Fuente B
1999 Aug;138(2 Pt 1):313-318, American heart journal
BACKGROUND: Recent trials have demonstrated an association between high activated partial thromboplastin time (aPTT) and bleeding, intracranial hemorrhage, reinfarction, and death in patients with acute coronary syndromes treated with heparin. Of all the factors that affect aPTT in patients treated with heparin, body weight is most strongly correlated. METHODS: We compared the efficacy of 2 weight-adjusted heparin regimens (groups 2 and 3) and the standard (group 1) non-weight-adjusted 5000-U intravenous bolus/1000 U/hr infusion to achieve an aPTT between 45 and 70 seconds in a nonrandomized prospective cohort of 80 patients admitted with unstable angina and non-ST elevation myocardial infarction. RESULTS: Patients treated with the lower dose of weight-adjusted heparin (60 U/kg intravenous bolus, maximum of 4000 U; 12 U/kg/hr, maximum 900 U/kg), group 3, were more often within the target range for aPTT at 6 hours (34% vs 5% vs 0%) and required fewer heparin infusion changes (1.0 +/- 1.0 vs 1.9 +/- 1.0 vs 2.0 +/- 0.9) within the first 24 hours compared with the other regimens. Patients in groups 1 and 2 were overwhelmingly above target range at 6 hours (95% and 84%, respectively, compared with 48% in group 3). CONCLUSIONS: Traditional heparin dosing regimens result in marked initial overanticoagulation in patients with acute coronary syndromes, which may place these patients at higher risk of adverse outcomes. A lower dose weight-adjusted heparin regimen is superior in achieving early aPTTs within the target range and reducing the need for infusion changes over the ensuing 24 hours
— id: 38948, year: 1999, vol: 138, page: 313, stat: Journal Article,

Cardiogenic shock in patients with acute ischemic syndromes with and without ST-segment elevation
Holmes DR Jr; Berger PB; Hochman JS; Granger CB; Thompson TD; Califf RM; Vahanian A; Bates ER; Topol EJ
1999 Nov 16;100(20):2067-2073, Circulation
BACKGROUND: Cardiogenic shock is usually considered a sequela of ST-segment elevation myocardial infarction. There are limited prospective data on the incidence and significance of shock in non-ST-segment elevation patients. This study assessed the incidence and outcomes of cardiogenic shock developing after enrollment among patients with and without ST-segment elevation in the Global Use of Strategies To Open Occluded Coronary Arteries (GUSTO)-IIb trial. METHODS AND RESULTS: Among 12,084 patients in GUSTO-IIb who did not present with cardiogenic shock, 4092 (34%) had and 7991 (66%) did not have ST-segment elevation on the enrollment ECG. Cardiogenic shock developed in 4.2% of ST-segment elevation patients compared with 2.5% of patients without ST-segment elevation (odds ratio, 0. 581; 95% CI, 0.472 to 0.715; P<0.001). Shock developed significantly later among patients without ST-segment elevation. There were significant differences in baseline characteristics between shock patients with and without ST-segment elevation: Patients without ST-segment elevation were older, more frequently had diabetes mellitus and 3-vessel disease, but had less TIMI grade 0 flow at angiography. Regardless of the initial ECG, mortality was high: 63% among patients with ST-segment elevation and 73% in those without ST-segment elevation. CONCLUSIONS: Cardiogenic shock occurs in the setting of acute ischemic syndromes regardless of whether ST-segment elevation is present. The incidence, patient characteristics, timing, clinical course, and angiographic findings differ between the 2 groups. Mortality from cardiogenic shock is similarly high among patients with and without ST-segment elevation
— id: 38947, year: 1999, vol: 100, page: 2067, stat: Journal Article,

The use of intraaortic balloon counterpulsation as an adjunct to reperfusion therapy in cardiogenic shock
Bates ER; Stomel RJ; Hochman JS; Ohman EM
1998 May 29;65 Suppl 1(2):S37-S42, International journal of cardiology
Modern coronary care unit interventions have not reduced the high mortality rate associated with cardiogenic shock due to acute myocardial infarction. Results with thrombolytic therapy have also been disappointing because of poor infarct artery patency rates in a low coronary flow state. Percutaneous transluminal coronary angioplasty appears to be a beneficial intervention, but the technique is not available at most hospitals. Intraaortic balloon counterpulsation provides temporary hemodynamic and clinical improvement in the majority of patients with cardiogenic shock. The use of intraaortic counterpulsation to augment patency rates with thrombolytic therapy or to stabilize patients for transfer to a hospital with angioplasty services appears to be a promising strategy for hospitals without an interventional cardiac catheterization laboratory
— id: 38955, year: 1998, vol: 65 Suppl 1, page: S37, stat: Journal Article,

Effects of prior aspirin and anti-ischemic therapy on outcome of patients with unstable angina. TIMI 7 Investigators. Thrombin Inhibition in Myocardial Ischemia
Borzak S; Cannon CP; Kraft PL; Douthat L; Becker RC; Palmeri ST; Henry T; Hochman JS; Fuchs J; Antman EM; McCabe C; Braunwald E
1998 Mar 15;81(6):678-681, American journal of cardiology
Both aspirin and beta-adrenergic blocking drugs have been shown to reduce the risk of death or acute myocardial infarction (AMI) in patients with unstable angina, but their effect during chronic use on the presentation of acute coronary syndromes is less well defined. Calcium antagonists and oral nitrates are also widely prescribed for patients with coronary disease, but their effect on presentation of acute myocardial ischemia is unknown. We retrospectively examined the effects of prior aspirin and anti-ischemic medical therapy on clinical events in 410 patients hospitalized for unstable angina. Ischemic pain occurred at rest for a duration of 5 to 60 minutes. During hospitalization, 97% of patients received aspirin and all received the direct thrombin inhibitor bivalirudin for at least 72 hours. Despite being older and more likely to have risk factors for coronary disease and poor outcome, patients receiving aspirin before admission were less likely to present with non-Q-wave AMI (5% vs 14% in patients not on aspirin, p = 0.004). Prior beta blocker, calcium antagonist, or nitrate administration did not appear to modify presentation as unstable angina or non-Q-wave AMI. In a multivariate model, the combined incidence of death, AMI not present at enrollment, or recurrent angina was best predicted by age (adjusted odds ratio [95% confidence interval] 2.38 [1.14 to 3.98]) and presence of electrocardiographic changes with pain on presentation (adjusted odds ratio 2.83 [1.50 to 5.35]) but was not related to prior or in-hospital medical therapy. Thus, aspirin but not anti-ischemic therapy before hospitalization of patients with unstable angina was associated with a decreased incidence of non-Q-wave AMI on admission
— id: 38956, year: 1998, vol: 81, page: 678, stat: Journal Article,

Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. TIMI Investigators. Thrombolysis in Myocardial Infarction
Hochman JS; McCabe CH; Stone PH; Becker RC; Cannon CP; DeFeo-Fraulini T; Thompson B; Steingart R; Knatterud G; Braunwald E
1997 Jul;30(1):141-148, Journal of the American College of Cardiology
OBJECTIVES: Women and men enrolled in the Thrombolysis in Myocardial Infarction (TIMI) IIIB trial of unstable angina and non-Q wave myocardial infarction (MI) were evaluated to determine gender differences in characteristics and outcome. BACKGROUND: Coronary heart disease is the leading cause of death for women and men. However, the characteristics and outcome of women compared with men with unstable angina and non-Q wave MI have not been extensively studied. METHODS: The characteristics, outcomes and proportion of 497 women and 976 men with unstable angina and non-Q wave MI at the time of enrollment were compared. When these proportions were noted to be significantly different, we compared them with the 7,731-patient TIMI IIIB Registry, which represents the non-trial, screened population with these syndromes at these centers. RESULTS: For both coronary syndromes, women were older, were less frequently white, had a higher incidence of diabetes and hypertension and were receiving more cardiac medications. The 42-day rate of death and MI in TIMI IIIB was similar for women and men (7.4% vs. 7.5%). Coronary angiography revealed less severe coronary artery disease for women than for men, with absence of critical obstructions in 25% versus 16% and mean ejection fractions 62 +/- 12% versus 57 +/- 13% for women versus men (p < 0.01). Medical management failed in women as often as in men, and rates of cardiac catheterization and percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery were similar for women and men in the conservative strategy arm as well as in the invasive strategy arm. Women in the TIMI IIIB trial had proportionately more unstable angina than did men. The proportion of unstable angina and non-Q wave MI for women was similar in the trial and Registry. However, proportionately more men in the trial had non-Q wave MI than men in the Registry. CONCLUSIONS: 1) Women with each acute coronary syndrome are older than men and have more comorbidity. 2) The outcome with unstable angina and non-Q wave MI is related to severity of illness and not gender. 3) Mortality associated with revascularization for unstable angina and non-Q wave MI was similar for women and men. 4) The proportion of women and men enrolled with each acute coronary syndrome is different. These rates reflect both the prevalence of disease and selection bias owing to trial eligibility criteria and other identified factors
— id: 38957, year: 1997, vol: 30, page: 141, stat: Journal Article,

Functional consequences of acute collagen degradation studied in crystalloid perfused rat hearts
Todaka K; Jiang T; Chapman JT; Gu A; Zhu SM; Herzog E; Hochman JS; Steinberg SF; Burkhoff D
1997 Jun;92(3):147-158, Basic research in cardiology
OBJECTIVES: The impact of acute collagen disruption by the disulfide donor, 5,5'-dithio-2-nitrobenzoic acid (DTNB) on ventricular properties was tested in rat hearts. METHODS: Collagen was degraded acutely in 13 isolated, isovolumically contracting rat hearts by perfusion with 1 mM DTNB added to Krebs-Henseleit solution for 1 hour followed by 2-hour perfusion with normal solution. Another 13 hearts were perfused with normal solution for 3 hours (Control). RESULTS: Collagen content was 3.5 +/- 0.5% of ventricular dry weight in control group compared with 2.1 +/- 0.4% in DTNB group (decrease by 40%, p < 0.01). Scanning electron micrographs revealed loss of the delicate collagen network surrounding muscle fibers in DTNB treated hearts. Developed pressure at a fixed volume decreased to 86 +/- 17% of the baseline value after 3-hour perfusion in the control group, whereas in DTNB treated hearts developed pressure fell to 68 +/- 13% (p < 0.01). End-diastolic pressure was set at 5 mmHg at the beginning of the experiment and rose to 15 +/- 8 mmHg in control and 30 +/- 13 mmHg (p < 0.01) in the treated hearts. Concomitantly, wet-to-dry weight ratio increased from 5.63 +/- 0.26 in control to 6.07 +/- 0.11 (p < 0.05) in the DTNB treated hearts. A separate set of experiments on isolated myocytes excluded the possibility of a direct effect of DTNB on myocyte contractile function. CONCLUSIONS: These data suggested that with 40% collagen disruption by DTNB there is a significant increase in tissue edema that results in a decrease in chamber capacitance; in addition, there is a significant decrease in systolic performance which reflects the combined effect of edema and loss of collagen
— id: 38958, year: 1997, vol: 92, page: 147, stat: Journal Article,

Has the time come to seek and open all occluded infarct-related arteries after myocardial infarction?
Hochman JS
1996 Oct;28(4):846-848, Journal of the American College of Cardiology
— id: 38959, year: 1996, vol: 28, page: 846, stat: Journal Article,

Interaction of ischaemia and encainide/flecainide treatment: a proposed mechanism for the increased mortality in CAST I
Greenberg HM; Dwyer EM Jr; Hochman JS; Steinberg JS; Echt DS; Peters RW; Patt MV
1995 Dec;74(6):631-635, British heart journal
OBJECTIVE--To determine whether an interaction between encainide or flecainide and intercurrent ischaemia could account for the observed increase in cardiac and sudden deaths in the study group in the Cardiac Arrhythmia Suppression Trial (CAST) I. DESIGN--CAST I was a randomised, double blind, placebo controlled study in which patients received the drug which suppressed at least 6 premature ventricular contractions per minute by 80% or episodes of non-sustained ventricular tachycardia by 90%. Arrhythmic sudden death or aborted sudden death were the study end points. Measured secondary end points included recurrent myocardial infarction, new or increasing angina pectoris, congestive heart failure, and syncope. The CAST I database was analysed to determine which of three end points occurred first--cardiac death or cardiac arrest, angina pectoris, or non-fatal recurrent infarction. They were regarded as mutually exclusive end points. The triad of cardiac or sudden arrhythmic death plus congestive heart failure and syncope was similarly analysed. RESULTS--It was assumed that recurrent non-fatal infarction and new or increasing angina pectoris were ischaemic in origin. The sum of these non-fatal ischaemic end points and sudden death were nearly identical in the placebo group (N = 129) and the treatment group (N = 131). The one year event rate in each group was 21%. However, the treatment group had a much greater fatality rate (55 v 17; P < 0.0001) than the placebo group. The same relation was found when the data were examined on the basis of drug exposure rather than intention to treat. The temporal and circadian events were similar in each group and were consistent with an ischaemic pattern. No such patterns emerged from analysis of the presumed non-ischaemic end points of congestive heart failure and syncope. CONCLUSIONS--These data suggest that the interaction between active ischaemia and treatment with encainide or flecainide may have been responsible for the increased mortality seen in the treatment group in CAST I. This conversion of a non-fatal to a fatal event emphasises the need for future antiarrhythmic drugs to be screened in ischaemic models
— id: 113735, year: 1995, vol: 74, page: 631, stat: Journal Article,

Current spectrum of cardiogenic shock and effect of early revascularization on mortality. Results of an International Registry. SHOCK Registry Investigators
Hochman JS; Boland J; Sleeper LA; Porway M; Brinker J; Col J; Jacobs A; Slater J; Miller D; Wasserman H; et al.
1995 Feb 1;91(3):873-881, Circulation
BACKGROUND: Cardiogenic shock remains the leading cause of death of patients hospitalized with acute myocardial infarction (MI). This study was conducted to examine (1) the current spectrum of cardiogenic shock, (2) the proportion of patients who are potential candidates for a trial of early revascularization, and (3) the apparent impact of early revascularization on mortality. METHODS AND RESULTS: Nineteen participating centers in the United States and Belgium prospectively registered all patients diagnosed with cardiogenic shock. Two hundred fifty-one patients were registered. The mean age was 67.5 +/- 11.7 years, and 43% were women. Acute mitral regurgitation or ventricular septal rupture was the cause of shock in 8%. Concurrent conditions contributing to the development of shock were noted in 5%, and 2% had isolated right ventricular shock. Among the remaining 214 patients, nonspecific findings on the ECG associated with 'nontransmural' MI were seen in 14%. The median time to shock diagnosis after MI was 8 hours. The overall in-hospital mortality was 66%. Patients clinically selected to undergo cardiac catheterization were significantly younger and had a lower mortality than those not selected (51% versus 85%, P < .0001) even if they were not revascularized (58%). Mortality for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) was 60% (n = 55) and 19% (n = 16) for coronary artery bypass graft surgery (CABG). Sixty percent (n = 150) of registered patients were judged eligible for a trial of early revascularization. Trial-eligible patients were significantly younger (65.4 +/- 11.0 versus 70.6 +/- 11.9 years, P < .001), had an earlier median time to shock onset after MI (6.5 versus 17.5 hours, P = .003), and had lower mortality (62% versus 73%, P = .077) than ineligible patients. CONCLUSIONS: Patients diagnosed with cardiogenic shock complicating acute MI are a heterogeneous group. Those eligible for a trial of early revascularization tended to have lower mortality. Patients selected to undergo cardiac catheterization had lower mortality whether or not they were revascularized. Emergent PTCA and CABG are promising treatment modalities for cardiogenic shock, but biased case selection for treatment may confound the data. Whether PTCA and CABG reduce mortality and which patient subgroups benefit most remain to be determined in a randomized clinical trial
— id: 38960, year: 1995, vol: 91, page: 873, stat: Journal Article,

Indications for immediate angiotensin-converting enzyme inhibition in patients with acute myocardial infarction
LeJemtel TH; Hochman JS; Sonnenblick EH
1995 Jun;25(7 Suppl):47S-51S, Journal of the American College of Cardiology
When initiated a few days after myocardial infarction, angiotensin-converting enzyme inhibition exerts beneficial effects on survival and morbidity in patients with asymptomatic left ventricular systolic dysfunction or symptomatic heart failure. During the acute phase of a myocardial infarction, angiotensin-converting enzyme inhibition appears to be well tolerated, to prevent the development of heart failure in patients with asymptomatic left ventricular systolic dysfunction and to improve the hemodynamic and clinical variables of heart failure when present. Accordingly, early angiotensin-converting enzyme inhibition is clearly indicated in patients with acute myocardial infarction associated with asymptomatic left ventricular dysfunction or clinical evidence of heart failure. Angiotensin-converting enzyme inhibition may also be beneficial when thrombolytic agents fail to restore coronary patency in patients with acute myocardial infarction
— id: 43528, year: 1995, vol: 25, page: 47S, stat: Journal Article,

Prognostic significance of left ventricular aneurysm in the Cardiac Arrhythmia Suppression Trial (CAST) population
Hochman, J S; Brooks, M M; Morris, M; Ahmad, T; Patt, M
1994 Apr;127(4 Pt 1):824-832, American heart journal
Left ventricular aneurysm has been associated with increased mortality rates. The Cardiac Arrhythmia Suppression Trial (CAST) database was used prospectively to assess (1) the prognostic significance of left ventricular (LV) aneurysm after myocardial infarction on mortality rates and (2) the relation of LV aneurysm to ventricular arrhythmias and their suppressibility. All patients in the CAST study were enrolled after myocardial infarction. They had > or = 6 ventricular premature depolarizations (VPDs) per hour and ejection fraction < or = 55%; they were enrolled in the study an average of 96 days after the index myocardial infarction. Of 2494 patients with wall motion data, 164 had LV aneurysm, 600 had only dyskinesis, 913 had only akinesis, and 817 had none of these. Radionuclide scan was used in 39%, two-dimensional echocardiography in 30%, and LV angiogram in 31%. Baseline VPDs and nonsustained ventricular tachycardia were similar in all groups. LV aneurysm patients were more frequently eliminated during open-label titration. The incidence of sustained VT during follow-up was only 2.8% for aneurysm patients, a rate that was similar to the other groups. Patients with LV aneurysm had significantly lower survival rates (82% vs 91%) at 16 months after study entry than those without these wall motion abnormalities (p < 0.005). When survival rates were adjusted for ejection fraction there was still a moderately large hazard ratio (1.34) of LV aneurysm that was not statistically significant (p = 0.18). We conclude that (1) the presence of LV aneurysm does not independently worsen prognosis, and (2) older concepts of LV aneurysm and ventricular arrhythmias must be reevaluated
— id: 113730, year: 1994, vol: 127, page: 824, stat: Journal Article,

Effects of thrombolytic therapy administered 6 to 24 hours after myocardial infarction on the signal-averaged ECG. Results of a multicenter randomized trial. LATE Ancillary Study Investigators. Late Assessment of Thrombolytic Efficacy
Steinberg JS; Hochman JS; Morgan CD; Dorian P; Naylor CD; Theroux P; Topol EJ; Armstrong PW
1994 Aug;90(2):746-752, Circulation
BACKGROUND: Thrombolytic therapy reduces mortality after acute myocardial infarction, even when treatment is initiated relatively late after onset of symptoms. The mechanism underlying this survival benefit is incompletely understood. METHODS AND RESULTS: In a prospectively designed ancillary study of a randomized, placebo-controlled trial of late thrombolytic therapy (LATE), the signal-averaged (SA) ECG was recorded before hospital discharge in an effort to assess the effect of thrombolytic therapy on arrhythmia substrate. Three hundred ten patients were enrolled at 23 participating sites; 160 patients received placebo, and 150 patients received recombinant tissue-type plasminogen activator (rTPA) therapy 6 to 24 hours after onset of symptoms. Compared with placebo, rTPA tended to reduce the frequency of SAECG abnormality (filtered QRS duration > 120 milliseconds) by 37% (95% CI, -64%, +6%; P = .087) and the filtered QRS duration (105.7 +/- 13.8 versus 108.8 +/- 14.6 milliseconds, P = .05). In the prespecified subgroup of 185 patients with ST elevation on the qualifying ECG, rTPA resulted in a 52% reduction (95% CI, 4% to 77%, P = .011) of SAECG abnormality and a shorter filtered QRS duration (105.7 +/- 10.9 versus 110.7 +/- 15.9 milliseconds, P = .01). No benefit was seen in patients without ST elevation on ECG. CONCLUSIONS: Late thrombolytic therapy produced a more stable electrical substrate, which probably represents an important mechanism of mortality benefit
— id: 38961, year: 1994, vol: 90, page: 746, stat: Journal Article,

Acute myocardial infarction triggered by emotional stress
Gelernt MD; Hochman JS
1992 Jun 1;69(17):1512-1513, American journal of cardiology
— id: 38962, year: 1992, vol: 69, page: 1512, stat: Journal Article,

Effect of atenolol on myocardial infarct expansion in a nonreperfused rat model
Hochman JS; Wong SC
1991 Sep;122(3 Pt 1):689-694, American heart journal
Acute myocardial infarct expansion is associated with a poor prognosis. This study was performed to assess potential beneficial effects of beta-blockers on inhibiting expansion. A pilot study showed that atenolol (10 mg/kg) achieved sustained beta-blockade in rats. In the main study, following left coronary ligation, 36 rats received atenolol and 18 rats received placebo daily for 7 days. Infarct size was similar in treated and control rats (25 +/- 13% versus 28 +/- 11%). Expansion grades and a quantitative index of expansion were similar for both groups. Infarct size and expansion index were significantly related, but linear regression lines were similar for treated and control rats. We conclude that atenolol has no significant effect on infarct expansion in this nonreperfused rat model
— id: 38963, year: 1991, vol: 122, page: 689, stat: Journal Article,

The distribution of atherosclerotic lesions in the coronary arterial tree: relation to cardiac risk factors
Hochman JS; Phillips WJ; Ruggieri D; Ryan SF
1988 Nov;116(5 Pt 1):1217-1222, American heart journal
Although it is often stated that proximal atherosclerotic coronary artery disease occurs more frequently than distal disease, several autopsy studies have disputed this. To examine the prevalence of proximal vs mid and distal disease and its relationship with cardiac risk factors, we studied more than 14,000 sections from 102 hearts with coronary artery disease at autopsy. After postmortem angiography, the coronary arteries were removed, divided into proximal, mid, and distal thirds, sectioned at 2.5 mm intervals, and graded for percentage reduction in cross-sectional area by atherosclerosis. Of 252 vessels in 84 patients with greater than or equal to 75% stenosis, 166 (66%) has proximal disease vs 107 (42%) with mid disease and 40 (16%) with distal disease (p less than 0.001). No patient had a mid or distal stenosis greater than 75% without proximal disease. When atherosclerosis of any severity was assessed, proximal atherosclerotic lesions were long and diffuse, whereas distal lesions were more often short and discrete. Proximal circumflex lesions were shorter in length than those in the right or left anterior descending coronary arteries. The prevalence of proximal, mid, and distal stenoses in 25 diabetic patients was similar to that in nondiabetic persons (53%, 47%, and 17%, p greater than 0.3). Similarly, hypertension, smoking, and obesity were not associated with an increase in prevalence of distal disease. Patients with distal stenoses were younger than patients without (mean age, 64 +/- 13 vs 73 +/- 10 years, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
— id: 38964, year: 1988, vol: 116, page: 1217, stat: Journal Article,

Limitation of myocardial infarct expansion by reperfusion independent of myocardial salvage
Hochman JS; Choo H
1987 Jan;75(1):299-306, Circulation
Very early reperfusion after coronary occlusion can reduce infarct size and preserve left ventricular function. Whether later reperfusion is of benefit is unclear. We studied the effect of very early reperfusion with myocardial salvage and 'late' reperfusion without myocardial salvage on infarct expansion and aneurysm formation. Sixty-eight rats underwent left coronary artery ligation and were randomized to 30 min reperfusion, 2 hr reperfusion, or permanent coronary artery ligation. The animals were killed and the hearts examined at 2 weeks. Thirty minute reperfusion reduced infarct size, extent of transmurality, and infarct expansion. Two hour reperfusion reduced neither infarct size nor transmurality but inhibited infarct expansion. The results of this study in the rat preparation suggest a beneficial effect of 'late' reperfusion on infarct expansion independent of myocardial salvage. If these results are confirmed in human beings, the period after myocardial infarction during which a patient can be considered for thrombolytic therapy or reperfusion by percutaneous transluminal coronary angioplasty could be greatly prolonged
— id: 38965, year: 1987, vol: 75, page: 299, stat: Journal Article,

Effect of exercise on acute myocardial infarction in rats
Hochman JS; Healy B
1986 Jan;7(1):126-132, Journal of the American College of Cardiology
Infarct expansion, the time-related thinning and dilation of an acute transmural infarct, leads to aneurysm formation and cardiac rupture in humans. In this study, the effect of exercise on acute infarct expansion early after myocardial infarction was examined in 129 rats. Ninety rats were exercised on a treadmill for 1.5 hours daily for 1 week beginning on the day of coronary artery ligation; the remaining 39 rats remained in their cages. There was no effect on the prevalence or extent of expansion; specifically, infarct wall thickness, left ventricular diameter and expansion grade (0 to 4+) were similar in the exercise and control rats. There was no difference in infarct size or the number of animals with aneurysmal shape changes in the exercise and control groups. There was no significant difference between the two groups in the histologic finding of intramural hemorrhage, a feature that has been associated with cardiac rupture, and no complete rupture was seen. However, there was a nonsignificant trend toward higher mortality in the exercised group. Thus, the findings of this study suggest that moderate exercise early after myocardial infarction produces no significant detrimental effect on infarct size or left ventricular topography in the rat model
— id: 38966, year: 1986, vol: 7, page: 126, stat: Journal Article,

The heart in polyarteritis nodosa: a clinicopathologic study
Schrader ML; Hochman JS; Bulkley BH
1985 Jun;109(6):1353-1359, American heart journal
— id: 38967, year: 1985, vol: 109, page: 1353, stat: Journal Article,

Endocardial abnormalities in left ventricular aneurysms. A clinicopathologic study
Hochman JS; Platia EB; Bulkley BH
1984 Jan;100(1):29-35, Annals of internal medicine
To correlate morphologic subgroups of left ventricular aneurysms with the major clinical manifestations (ventricular arrhythmias, congestive heart failure, and systemic emboli), we studied 73 patients with such aneurysms--34 at autopsy and 45 after surgical excision. Sixty-three patients had a history of congestive heart failure, 5 had systemic emboli, and 28 had recurrent ventricular tachycardia. Two types of endocardial abnormalities were noted: thick endocardial plaque composed of fibrous elastic tissue that contained little or no thrombus (type I, 30 patients); and aneurysms with little or no endocardial fibroelastosis (type II, 43 patients), some with layers of thrombus obliterating the aneurysmal cavity. Emboli only occurred in 5 patients with type II aneurysms who had mural thrombi. Recurrent ventricular tachycardia occurred in 20 patients with type I aneurysms but only in 8 with type II (p less than 0.001), showing a relation between endocardial fibroelastosis and ventricular tachycardia. Structural differences in ventricular aneurysms thus appear to have pathophysiologic significance. Our findings have implications for the mechanisms of ventricular tachycardia in postinfarction patients and for its prevention by endocardial resection
— id: 38968, year: 1984, vol: 100, page: 29, stat: Journal Article,

Expansion of acute myocardial infarction: an experimental study
Hochman JS; Bulkley BH
1982 Jun;65(7):1446-1450, Circulation
Expansion (regional dilatation and thinning) of acutely infarcted myocardium in man has been shown to correlate with overall cardiac dilatation and rupture. We studied gross and histopathologic features and the time course of expansion in rats. Infarcts were produced in 84 rats by ligation of the left coronary artery and studied at 1, 2, 3, 4, 5 and 7 days. All hearts were prepared by potassium diastolic arrest, gel distention and fixation. Expansion was graded 0 to 4+ : 1+, mild thinning of infarcted wall; 2+, mild thinning and dilatation; 3+, moderate thinning and dilatation; and 4+, marked thinning and dilatation. There were 80 transmural infarcts, and 66% showed expansion; 36 of 80 (45%) were graded 1-2+ and 17 of 80 (21%) 3-4+. None of the four exclusively nontransmural infarcts showed expansion. Expansion was present in 61% of transmural infarcts at 1-2 days, in 65% at 3-4 days and in 80% at 5-7 days. The percentage of rats with severe (3-4+) expansion increased markedly over this period, from 0% at 1-2 days to 23% at 3-4 days to 65% at 5-7 days. Histopathologic infarct evolution was roughly twice as rapid as that of humans; 5-7 day-old infarcts showed well-developed granulation tissue. Thus, expansion can be produced in an animal model. A critical infarct size of 17% appeared necessary for significant (greater than 1+) expansion, and the degree of expansion correlated with infarct size. Although this phenomenon begins early after infarction, its extent progresses over days, making interventions to interrupt its development feasible
— id: 56391, year: 1982, vol: 65, page: 1446, stat: Journal Article,

Pathogenesis of left ventricular aneurysms: an experimental study in the rat model
Hochman JS; Bulkley BH
1982 Jul;50(1):83-88, American journal of cardiology
Left ventricular aneurysms, convex protrusions at sites of transmural scar, are clinically recognized late after myocardial infarction because of their hemodynamic or arrhythmic complications. Whether aneurysms develop from dilation of freshly infarcted myocardium early after myocardial infarction or from late dilation of scar is not known. To investigate this question, the time course of changes in shape of the left ventricle early and late after myocardial infarction was studied. One hundred forty-one myocardial infarcts were produced in rats by coronary ligation, and the animals were killed at time periods of up to 6 weeks. True aneurysms developed as early as 2 weeks and only in rats with a transmural infarct. The percent of rats that manifested 'aneurysmal shape changes' (defined as a protrusion of the full thickness of the left ventricular wall) increased from day 1 to day 5, but did not change significantly thereafter. The extent of left ventricular dilation in hearts with early aneurysmal shape changes did not progress significantly up to day 42. Accordingly, in the rat, regional aneurysmal shape alterations are due not to late dilation of scare tissue, but rather to 'expansion' of freshly necrotic myocardium within the first 5 days of infarction. Thus, early changes in shape appear to determine late aneurysm formation
— id: 38970, year: 1982, vol: 50, page: 83, stat: Journal Article,

Serum estrogen levels in men with acute myocardial infarction
Klaiber EL; Broverman DM; Haffajee CI; Hochman JS; Sacks GM; Dalen JE
1982 Dec;73(6):872-881, American journal of medicine
Serum estradiol and serum estrone levels were assessed in 29 men in 14 men in whom myocardial infarction was ruled out; in 12 men without apparent coronary heart disease but hospitalized in an intensive care unit; and in 28 men who were not hospitalized and who acted as control subjects. (The 12 men who were hospitalized but who did not have coronary heart disease were included to control for physical and emotional stress of a severe medical illness.) Ages ranged from 21 to 56 years. Age, height, and weight did not differ significantly among groups. Blood samples were obtained in the patient groups on each of the first three days of hospitalization. The serum estrone level was significantly elevated in all four patient groups when compared with that in the control group. Estrone level, then, did not differentiate patients with and without coronary heart disease. Serum estradiol levels were significantly elevated in the groups with myocardial infarction, unstable angina, and in the group in whom myocardial infarction was ruled out. However, estradiol levels were not significantly elevated in the group in the intensive care unit without coronary heart disease when compared to the level in the normal control group. Serum estradiol levels, then, were elevated in men with confirmed or suspected coronary heart disease but were not elevated in men without coronary heart disease even under the stressful conditions found in an intensive care unit. Serum estradiol levels were significantly and positively correlated (p less than 0.03) with serum total creatine phosphokinase levels in the patients with myocardial infarction. The five patients with myocardial infarction who died within 10 days of admission had markedly elevated serum estradiol levels. The potential significance of these serum estradiol elevations is discussed in terms of estradiol's ability to enhance adrenergic neural activity and the resultant increase in myocardial oxygen demand
— id: 38969, year: 1982, vol: 73, page: 872, stat: Journal Article,