A34 Selected abstracts from the XIVth World Congress of Cardiology, May 5-9,2002 Heart, Lung and Circulation 2003; 12 Prospective Evaluation of a Chest Pain Pathway in the Coronary Care Unit at Green Lane Hospital; One Year Follow Up Study John I Edmond’, John K French*, Hanneke Hennyz, Ralph AH Stewart’, Teena West’, Harvey IJ White’ ‘Green Lane Hospital, New Zealand; 2University of Amsterdam, the Netherlands Background Many patients with acute chest pain do not have clear evidence of an acute coronary syndrome, nor an obvious non cardiac source of the pain. These patients are often admitted to hospital for several days for investigation. Chest pain units have been developed to facilitate the rapid triage of patients with chest pain, and to allow safe early discharge. Methods To prospectively evaluate the efficacy and safety of a chest pain pathway within the coronary care unit at Green Lane Hospital, 423 patients with possible or probable ischaemic chest pain were studied between August 1999 and March 2000, of whom 173 (41%) without history, physical findings, elevated cardiac markers or ECG evidence requiring CCU admission were considered eligible for the pathway. It was aimed to discharge patients if cardiac markers and electrocardiograms (and exercise tests if appropriate) were normal at 6-8 h, and follow up was undertaken at one year. Of the 173 patients, 17 subsequently were found to have either elevated levels of cardiac markers (CK-MB > 4.0 pg/L or Troponin T t 0.10 pg/L) or ECG changes requiring more prolonged CCU admission. Results Of the 155 remaining patients who had normal cardiac markers at baseline and 6-8 h, the median duration of hospital stay was 17.3 h [IQR 8.2, 25.11; 111 (72%) stayed in hospital for less than 24 h. There were no inappropriate discharges subsequently discovered, and no readmissions within 30 days with acute coronary syndrome. In the year following discharge 9 patients had an episode of unstable angina, 3 had a myocardial infarction (one of whom later died) and 4 died of non cardiac causes. At one year, freedom from cardiac death or nonfatal MI was 98% [95% CI 95,100]. Conclusion The chest pain pathway used at Green Lane Hospital facilitated triage and had good event free survival. Approximately _ of these patients were discharged in under 8 h, but _ of patients remained in hospital for more than 24 h. Key words: Coronary artery disease, Emergency care, Unstable angina Blinded adjudication of non fatal reinfarction in patients following fibrinolytic therapy - Results from the HERO-2 trial John K French’, Phil A Aylward2, Barbara Williams’, Carmine De Pasquale2, Chris Hammett’, Ivor Gerber’, R John Simes3, Harvey D White’ ‘Green Lane Hospital, New Zealand; 2Flinders Medical Centre, Australia; 3NHMRC Clinical Trials Centre, Australia Background Non-fatal reinfarction in patients treated with fibrinolytic therapies is often the major secondary end point in large randomised clinical trials (RCTs), and is associated with decreased one year survival. In previous RCTs of treatments in ST elevation MI (including LBBB), the local investigators have reported the frequencies of nonfatal reinfarction. Methods In the HERO-2 trial we prospectively defined criteria and adjudicated nonfatal reinfarction during the initial hospitalisation prior to, and after, 18 h from randomisation, including in association with percutaneous or surgical revascularisation. HERO-2 trial entry required patient presentation within 6 h of symptom-onset and ST segment elevation of > 1 mm in two contiguous leads (> 2 mm in leads Vl - V3) on the electrocardiogram. Patients were randomised to receive either intravenous heparin or bivalirudin prior to streptokinase. Results According to local investigators the frequency of reinfarction during the index hospitalisation was 4.0% (bivalirudin 3.5%; heparin 4.5%; OR 0.77 [95%Cls 0.67-0.90] P < 0.001) whereas the adjudicated frequency of reinfarction in hospital was 3.2% (bivalirudm 2.8%; heparin 3.6%; OR 0.78 [95%Cls 0.66-0.931 P = 0.004). Of potential cases of reinfarction identified on the case report form, 173 were adjudicated as no reinfarction for the following reasons: no supporting data (27%); partial but insufficient supporting data (57%), recurrent ST elevation but criteria for reMI not met following further reperfusion therapy (8%), recurrent clinical event but death occurred prior to fulfillment of reM1 criteria (8%). Conclusion The lower frequency of reinfarction following adjudication was largely attributed to the lack of data supporting the prespecified criteria of reinfarction from local investigators, though the odds ratio associated with bivalirudin treatment was similar. Key words: Clinical trials, Myocardial infarction, Treatment, Thrombin inhibitors, Thrombolysis A Cautionary Tale for Multivessel Stenting During Acute Myocardial Infarction: Sienificant Vasoconstriction of Non-culurit Lesions Colm G Han&t@ Yutaka Koyama, Helge H Rasmussen, Gregory IC Nelson, Peter S Hansen, Michael R Ward Royal North Shore Hospital, Australia Background Recently there has been a worldwide trend towards multivessel stenting in the setting of myocardial infarction, treating nonculprit lesions as well as the infarct-related lesion. However, not infrequently we noted that nonculprit lesion severity was significantly exaggerated by vasoconstriction at the time of infarction, raising the possibility that many nonculprit lesions may not need to be treated. Methods In this retrospective study we identified all patients in our infarct interventional database who had a lesion of > 50% stenosis (by operator report) in a noninfarct related artery and had additional angiography within 9 months of the index infarction. Angiographic stenosis was measured in each study by the QCA Medis system in orthogonal planes by operators blinded to study sequence. Patients were excluded if matching angiographic views were not obtained or when coronary artery bypass grafting had been performed to the study vessel. Medications, hemodynamics, clinical status and demographics were recorded for both studies. Data are mean f SD. Results lo/59 lesions were > 50% stenosis during the infarct study and < 50% at the noninfarct study [MLD 1.14 (0.37) mm vs. 1.76 (0.70) mm, P < 0.0001, and percentage stenosis 61.1 (9.1)% vs. 38.0 (6.3)%, P < 0.0001]. Conclusion Clinically significant vasoconstriction is common in nonculprit lesions at the time of infarction and aggressive intracoronary vasodilator administration may be advisable prior to treating nonculprit lesions at the time of infarction. Key words: Angiography, Myocardial infarction, Treatment, Stent, Vasoconstriction Improved Long-term Survival After Anterior Myocardial Infarction Treated By Direct AngioplastyKtenting with Remote Surgical Backup John M Elliott’, David W Smyth2, Justine Miller*, Jo Davis2, Mark Richards3 ‘Christchurch School of Medicine, New Zealand; 2New Zealand; 3Cardio- endocrine Research Group, Christchurch School of Medicine, University of Otago, New Zealand Background Between June 1995 and August 1998, we performed direct angioplasty/stenting (DPTCA) for acute myocardial infarction (MI) with backup from a surgical centre 220 km away. DPTCA procedures were available between 8 am and 8 pm. Methods In this analysis we compared patients who were enrolled in the Post Myocardial Infarction Study and treated for first anterior MI by DPTCA (n = 46) or thrombolysis (TS, n = 108). Patients were excluded from this analysis if they presented in cardiogenic shock, received rescue angioplasty, or had previous MI. Results Median age was 61 years (48-68,25-75th centile) in the DPTCA group and 63 years (53-70) in the TS group (P = 0.13), and 89% and 75% were men (P = 0.05). Two patients were transferred electively to the surgical centre for observation but neither received bypass surgery. At one year, cumulative mortality was 0% after DPTCA and 7% after TS (P = 0.06), death or reM1 had occurred in 2% and 17% (P = 0.01) and 20% and 30% had died or been readmitted with reM1 or unstable angina (P = 0.20). Kaplan Meier analysis after a median followup of 1508 days revealed a significant improvement in freedom from death (P = 0.014, see graphic), and death or reinfarction after DPTCA (P = 0.002), and a trend toward improvement in the combined endpoint of death, reinfarction, readmission with unstable angina or revascularisation (P = 0.076). Conclusion Direct angioplasty/stenting supported by remote surgical backup improves long-term survival after acute anterior MI. Key words: Angioplasty, Myocardial infarction, Treatment, Prognosis, Stent