Normal flow, low gradient aortic stenosis - is LVOT the determinant?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Severe aortic stenosis is characterized for a high mean gradient (>40mmHg) and an aortic valve area (AVA ≤1cm2). These patients present with a lower mean gradient (<40mmHg) and area (AVA ≤1cm2). However, the treatment strategies focus on the population with a reduced indexed stroke volume (≤35mL/m2). There is less clarity concerning those with a normal stroke volume. An important determinant of the area and stroke volume is the LVOT diameter, which may have a significant impact in the classification of the severity. There is some literature supporting an expected diameter according to the body surface area.

Purpose

This paper aims to analyse the population with normal flow, low gradient aortic stenosis, as well as compare the impact of the expected LVOT diameter in the classification of patients.

Methods

We present a retrospective study from all consecutive patients to whom an echocardiogram was performed in our hospital during the years 2017 and 2018 which meet the criteria for low gradient aortic stenosis. Comorbidities were analysed as well as echocardiographic variables to properly characterize aortic stenosis.

Results

A total of 79 patients met the criteria for normal flow, low gradient aortic stenosis with a valvular area ≤1cm2.  Mean age was 79.5 ± 8.6 years-old and 38% was male. The mean LVOT diameter was 2.11 ± 0.18 cm which correlated to a mean AVA of 0.88 ± 0.10 cm2. Should the LVOT diameter align with the expected diameter according to the formula [(5,7× BSA +12,1)/10], the mean LVOT diameter would be 2.18 ± 0.11 cm, which correlated to a mean AVA of 0.96 ± 0.22cm2. This represents a statistically significant difference in the value, with the expected diameter being 0.075cm higher than the measured (p = 0.002), which translates in a statistically significant higher AVA (+0.085, p < 0,001). With the above data, 31 (38.8%) patients would have been reclassified as moderate aortic stenosis, according to the recalculated AVA alone. Taking into account the indexed AVA, only 22 (27.8%) patients would be reclassified. 8 other patients (10.1%) would have been reclassified as low flow, low gradient aortic stenosis as the recalculated stroke volume would be lower than 35mL/m2.

Conclusion

This paper reminded us of the importance of an appropriately measured LVOT diameter, and the potential impact in reclassification of valvular heart disease. This is more important when the classification may alter our conduct. Other imaging techniques, such as transoesophageal echocardiogram or CT scan, may obviate the squared error of the LVOT measurement as well as account for the geometry of the LVOT, especially in dubious cases. Abstract Figure.

Is flow better in mL/m2 or mL/s - a practical reflection on aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Severe aortic stenosis is characterized for a high mean gradient (>40mmHg) and an aortic valve area (AVA ≤1cm2). There is a population of patients with discordant findings. These patients present with a lower mean gradient (<40mmHg) and area (AVA ≤1cm2).  This states are explained by a low flow (indexed SV ≤35ml/m2). Some studies demonstrated that a flow rate (determined by dividing SV by ejection time) inferior to 200 mL/s is also associated with poor prognosis. Can this be an alternative in stratifying patients with an AVA ≤1cm2?

Purpose

This paper aims to compare flow assessment by the conventional way with flow calculated in ml/s in patients with AVA ≤1cm2

Methods

We present a retrospective study from all consecutive patients to whom an echocardiogram was performed in our hospital during the years 2017 and 2018 which meet the criteria for low gradient aortic stenosis. Comorbidities were analysed for each subgroup as well as echocardiographic variables to properly characterize aortic stenosis.

Results

A total of 118 patients met the criteria for severe aortic stenosis with a valvular area ≤1cm2. This population was made up of 18 patients with severe aortic stenosis low flow, low gradient with depressed ejection fraction and 32 patients with preserved ejection fraction. The other 68 patients represented patients with a normal flow, low gradient aortic stenosis. There is a strong correlation between the variable SVi and Flow Rate (r = 0,796, p < 0,001). A linear regression shows that the flow rate equivalent to a SVi of 35mL/m2 in our sample is 203mL/s, near the value of other studies. 10 (31.3%) patients with severe aortic stenosis low flow, low gradient with preserved ejection fraction, 3 (16.7%) patients with severe aortic stenosis low flow, low gradient with depressed ejection fraction and 53 (77.9%) patients with normal flow, low gradient aortic stenosis would have a flow superior to 200mL/s.

Conclusion

The use of flow rate systematically would downgrade the severity of valvular lesions with possible need for intervention. However, in certain dubious cases its application may identify a subpopulation with need for further study and probable treatment, such as the patients with normal flow, low gradient aortic stenosis. Further studies of this subgroup of patients are warranted to reach any final conclusions. Abstract Figure.

Low gradient aortic stenosis - is survival that different between types and strategies

Funding Acknowledgements

Type of funding sources: None.

Introduction

Severe aortic stenosis is characterized for a high mean gradient (>40mmHg) and an aortic valve area (AVA ≤1cm2). There is a population of patients with discordant findings. These patients present with a lower mean gradient (<40mmHg) and a small area (AVA ≤1cm2). They encompass a population with specific characteristics and rather heterogeneous treatment approach and different prognosis

Purpose

This paper aims to enlighten to the prognosis of the different subpopulation of low gradient aortic stenosis, alone and according to the treatment strategies in a center without surgical ou percutaneous valvular intervention. 

Methods

We present a retrospective study from all consecutive patients to whom an echocardiogram was performed in our hospital during the years 2017 and 2018 which meet the criteria for low gradient aortic stenosis. Comorbidities were analysed for each subgroup as well as echocardiographic variables to properly characterize aortic stenosis and employed strategy and death.

Results

A total of 135 patients met the criteria for severe aortic stenosis with a valvular area ≤1cm2. This population was made up of 19 patients with severe aortic stenosis low flow, low gradient with depressed ejection fraction and 36 patients with preserved ejection fraction. The other 80 patients represented patients with a normal flow, low gradient aortic stenosis. Groups were similar in terms of age, sex, BMI, hypertension, dyslipidaemia, atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease and chronic coronary syndrome. In terms of diabetes there was a statistically significant difference (p = 0.019) with a lower prevalence in the group with low flow, low gradient and preserved ejection fraction. There was a statistically significant difference in survival at 24 months between groups (p = 0,004), with a mean survival of 13.6 months, 17.6months and 21 months for low flow low gradient with depressed ejection fraction, low flow low gradient with preserved ejection fraction and normal flow, low gradient patients, respectively. When analysing the treatment strategies, there were also statistically significant differences between the whole population of patients (p = 0.001) and each subgroup (low flow, low gradient with depressed ejection fraction – p <0,001; and normal flow low gradient – p = 0,005), with exception of patients with low flow low gradient and preserved ejection fraction (p = 0,081).

Conclusion

Our analyses brings to our attention a clear difference in prognosis between the subgroups analysed with a worse mean survival at 24 months in patients with low flow, low gradient and depressed ejection fraction. Furthermore, there seems to be a clear impact of treatment strategies in each group of patients and still some margin of improvement especially in patients without a clearly defined treatment strategy. Abstract Figure.  Abstract Figure.

Left atrial appendage velocity as an instrument of predicting atrial fibrillation recurrence after successful catheter ablation – a useful tool?

Introduction

Catheter ablation for the treatment of Atrial Fibrillation (AF) is a modality of treatment in growing expansion. However the sustained long term response in preventing AF recurrence is poor for most patients, namely in those with a dilated left atrium.

Purpose

Our aim was to assess the utility of an echocardiographic parameter for left atrium function, the left atrial appendage velocity (LAAV), in predicting recurrences after catheter ablation.

Methods

We performed a 9 year retrospective analysis of all patients who underwent a successful catheter ablation for the treatment of atrial fibrillation and had a valid pre-procedural transesophagic echocardiogram in a single expert centre. Medical records were analysed for demographic, procedural data and outcomes.

Results

Seventy-three (73) patients fulfilled all inclusion criteria and were analysed. The mean age was 62±11 with a male preponderance (58,7%). The majority of patients (82,7%) had preserved left ventricle ejection fraction. Only 46% of patient had a volumetric assessment of the left atrium dimensions prior to ablation, with slight, moderate and severe dilation of the left atrium in 20%; 8,6% and 28,6% of patients. Of the patients subjected to an AF ablation the average LAAV was 50,6±19 cm/s, with 78% of patients with normal atrial appendage velocities.

Patients with low LAAV (<40cm/s) had a higher proportion of AF recurrences at 3 and 6 months (58,3 vs 12,8% and 89% vs 21,7%; p<0,05 for all) with a linear correlation between the presence of recurrences and LAAV (LAAV of 39,1 vs 57,5 cm/s; p<0,05 OR 0,91 (CI 95% = 0,85–0,97); r2=0,34 at 3 months and LAAV of 43,5 vs 59 cm/s; p=0,01; OR 0,94 (CI 95% = 0,89–0,99); r2=0,24 at 6 months respectively). There was a trend towards association with recurrences at 1 year although it did not reach statistical significance. There was no significant difference in the use of antiarritmic drugs, either prior or post ablation, in both groups. It was not possible to assess the additive predictive value to the left atrium dimensions due to the low percentage of volumetric assessment of left atrium prior to AF ablation.

Conclusions

Patients with low left atrial appendage velocities had a lower long term success rate of catheter ablation, with higher rates of recurrence at 3 and 6 months and a trend towards higher recurrences at 1 year, with linear correlation which hypothesises the use of the left atrial appendage velocity as novel predictive parameter for an integrative model.

Funding Acknowledgement

Type of funding sources: None.

107 Low-flow low-gradient aortic stenosis: aortic valve area estimated by continuity equation versus simplified method of projected aortic valve area

Introduction

The evaluation of real severity of "low-flow low-gradient" aortic stenosis (LFLG AS) is particularly challenging. TOPAS study demonstrated that projected aortic valve area at a normal transvalvular flow rate (AVAproj) derived from dobutamine stress echocardiography (DSE) is superior to the traditional Doppler indices to discriminate true severe-AS and pseudosevere-AS.

Purpose

To compare two echocardiographic methods to estimate severity of LFLG AS with DSE (aortic valve area (AVA) estimated by continuity equation (AVA-CE) and simplified method of AVAproj) in patients (pts) with low transvalvular flow rate (<250mL/seg).

Methods

Unicentric, retrospective study, that included pts with LFLG AS undergoing DSE with low dose dobutamine protocol, during Nov 2013-Dec 2018 period. Evaluation at rest and peak DSE of vital signs, mean transaortic gradient, aortic VTI, LVOT VTI and VTI ratio, valvulo-arterial impedance (ZVA), AVA-CE, simplified method of AVAproj and global longitudinal strain (GLS).

Results

A total of 27 DSE were performed in 23 different pts, mean age of 76 ± 8 years, 82% male. At rest 55% in sinus rhythm, mean heart rate (HR) was 76 ± 12 bpm, mean systolic arterial pressure (SAP) was 122 ± 22 mmHg, mean ZVA 4.3 ± 2 mmHg/ml/m2; mean diameter of LVOT was 21,7 ± 2,6cm, mean of mean aortic gradients 21 ± 7 mmHg, 67% of pts had a VTI ratio at rest compatible with severe AS and remaining compatible with moderate AS. Estimated mean AVA-CE was 0.86 ± 0.29 cm2 with 67% of pts classified as severe AS. Mean left ventricular ejection fraction at rest was 31 ± 9%, systolic volume index 28,7 ± 8 mL/m2 and GLS -5,9%.

During low dose perfusion protocol of dobutamine

100% patients remained asymptomatic, mean HR was 110 ± 25 bpm, mean SAP was 123 ± 26 mmHg, mean ZVA 3.6 ± 1.7 mmHg/mL/m2, mean of mean aortic gradients 28 ± 9mmHg, 37% of pts presented VTI ratio compatible with severe AS and remaining compatible with moderate AS. Mean flow reserve was 16 ± 16% and mean GLS-7.2%. AVA-CE was 1,06 ± 0,35 cm2 with 56% of pts classified as severe AS and mean projected AVA was 1.01 ± 0.22cm2, without significant difference in AVA estimated by the two methods (p = 0.344). Projected AVA allowed re-classification of AS in 22% of pts (5 patients), with 31% of severe AS reclassified as moderate AS while AVA-CE allowed re-classification in 13% (3 patients), with 19% of severe AS reclassified as moderate AS.

Considering medium follow up of 24 months, 6 patients were submitted aortic valve replacement surgery and another 6 patients to transcatheter aortic valve replacement. The simplified projected valve area calculation show no significant therapeutic impact in the selection of this patients.

Conclusion

The simplified projected valve area calculation is technically feasible and accessible. This study shows a good correlation in pts with low cardiac flow. If AVAproj method had been used 2 extra patients would have been reclassified during DSE.

P1788 Prognostic value of stress echocardiography in preoperative risk stratification and management

Introduction

The prognostic value of pharmacologic stress echocardiography has been extensively demonstrated in patients undergoing noncardiac surgery since 42% of the perioperative complications are cardiac. Coronary artery stenoses can became flow-limiting due to hemodynamic fluctuations in this period leading to myocardial ischemia.

Purpose

Evaluation of prognostic value of pharmacologic stress echocardiography in preoperative risk stratification.

Methods

Single center retrospective analysis of patients’ data referred to perform a preoperative risk stratification through pharmacological stress echocardiography between January 2014- December 2018. Data was collected regarding clinical and echocardiographic parameters to predict perioperative cardiac complications (myocardial infarction and development of arrythmias) and evaluate the impact of the result of DSE in patients´ clinical management.

Results

Of 910 pharmacological stress echocardiograms, 106 were performed to evaluate preoperative risk. Patients´ mean age was 66 ± 11 years, 85% males. 64% had hypertension, 45% dyslipidaemia, 38% current smokers and 18% diabetes. 189% had previously myocardial infarction and 9% stroke. All patients were proposed to intermediate-high risk surgeries: 73% to vascular surgery, 14% to kidney transplant and 13% to other type of surgery (especially abdominal surgery). Most of the stress tests (64%) were performed with dobutamine and the others 34% with dipyridamole. 91% of stress echocardiography were negative, 6% positive and 4% inconclusive. The patients with a positive stress test was submitted to coronary angiography to treat relevant lesions and cardiovascular risk factors were optimized. 72% of the patients has already been submitted to the proposed surgery; in this population, there was a 5% rate of cardiac complications following the surgery, all in patients with previous negative stress echocardiography. Complications were non-ST elevation myocardial infarction in 1% and de novo atrial fibrillation in 4%. Half of the patients with a positive stress echocardiography were operated with no cardiac perioperative complications, possibly related to patient´s optimization before the surgery; in the other half it was decided not to perform the surgery due to the potential cardiac risk. Predictor factors for perioperative cardiac complications, evaluated through univariate and multivariate analysis, were age (odds ratios (OR) 1.232, confidence interval (CI) 1.043-1.456, p 0.007) and stroke (OR 0.057, CI 0.947-44.592, p 0.033).

Conclusion

In our study, patients with a positive stress echocardiography were optimized before the surgery leading to none cardiac perioperative complications, emphasizing the importance of this test in preoperative patients´ management.

P1551 Exercise echocardiographic determinants of exercise tolerance in aortic stenosis

Introduction

A variation of 20 mmHg in the mean aortic gradient in asymptomatic aortic stenosis (AS) was proposed as an indicator of severity during exercise echocardiography.

Objective

to identify echocardiographic predictors of exercise tolerance in AS and analyze the association of the variation in mean aortic gradient (MAG) with exercise tolerance.

Methods

prospective study of patients (pts) referred for testing with asymptomatic AS. We performed exercise echocardiography using the modified Bruce Protocol. Baseline, peak and recovery imaging was performed. Exercise tolerance was expressed as METS and % of predicted METS for age and sex.

Population

24 pts, 14 males, age 72+-9 years, body mass index (BMI): 28+-4 Kg/m2, etiology: bicuspid 6 pts, degenerative tricuspid 18 pts, 4 pts were in sinus rhythm, the remaining were in atrial fibrillation.

Results

baseline parameters: indexed aortic valve area (AVAi): 0,51+-0,13 cm2/m2, MAG 37+-12 mmHg, left ventricle: ejection fraction (LVEF): 63+-9%, cardiac index L/min/m2(CI) 3,2+-0,6, global longitudinal strain (LVGLS) -16+-3%, VTI ratio: 0,26+-0,05, valvulo-arterial impedance mmHg.ml-1.m2(Zva): 3,9+-0,9 . Peak parameters: AVAi: 0,54+-0,14 cm2/m2, MAG 53+-17 mmHg, LVEF: 69 (IQR 10)%, CI 3,2+-0,6, LVGLS -19+-5% , VTI ratio: 0,28+-0,06, Zva: 4,3+-1,4. Exercise tolerance: METS 6+-2, representing 86+-26% of the predicted exercise tolerance for age and sex.

Statistics

we performed an univariate analysis to identify the echocardiographic parameters associated with exercise tolerance, which were then used in a multiple regression analysis. A higher peak CI correlated with a higher exercise capacity (r = 0,5, p 0,01) and higher mean aortic gradient variation (r = 0,6 p < 0,01). The strongest predictor was the peak CI (B coefficient 0,5, R = 0,75, R² 0,57): when corrected for age, sex and BMI, for each increase of 0,5 mL/min/m2 in the peak CI we would expect an increase of 1 MET. This model explains 57 % of the variation in exercise capacity in these patients.

Conclusions

higher mean aortic gradient variation is associated with higher exercise tolerance and the strongest determinant of exercise tolerance in AS is the peak CI.

Atropine in exercise stress echocardiography? Case report

Stress echocardiography is widely used in the investigation of coronary heart disease. Exercise stress echocardiography offers the advantage of visualizing myocardial motion abnormalities during physiological stress testing. The authors report the use of atropine, as an adjunct to exercise echocardiography, in risk stratification after myocardial infarction.

[Assessment of aortic atherosclerosis with transesophageal echocardiography]

OBJECTIVE

To image the thoracic aorta by transesophageal echocardiography (TEE) and study atherosis (morphology and extent of atheroma plaques) and sclerosis (stiffness) and secondarily correlate them with serum lipid levels (cholesterol, HDL, LDL and triglycerides).

METHODS

We studied 29 patients (pts) who underwent TEE electively (male 18 pts, age 57.8 +/- 14.6 years). The parameters evaluated were: the stiffness coefficient = ln (PAsist/PAdiast)/(Dsyst/Dmin), and the morphology, location and extent of atheroma plaques. The systolic distension (Dsyst) was the difference between the maximal and the minimal dimensions (Dmin) of the aortic diameter measured by M mode. The lesions were classified in 4 degrees (0-3): 0--normal intima, 1--intimal thickening, 2--atheroma, 3--complicated lesion. Five aortic segments were studied: arch, D1-D4 (descending aorta at 5 cm intervals from the first 25 cm distal of the incisors line). We calculated the individual score = 1 x theta 1/180 + 2 x theta 2/180 + 3 x theta 3/180, theta n represents the angles occupied by the lesions and n (1-3) the severity of atherosis of each lesion. The total atherosis index (TAI) was sigma scores/(n. degree of visualized segments).

RESULTS

The arch was not visualized in 3 pts, and the segment D4 was only visualized in 3 pts. TAI mean = 0.82 +/- 0.74, stiffness coefficient mean (SC) = 9.56 +/- 15.072. There were no significant correlations between the lipid levels and the TAI or SC. The only significant positive correlations were: TAI vs age (r = 0.62, p < 0.001) and SC and diastolic blood pressure (BP) (r = 0.42, p < 0.05).

CONCLUSIONS

The best visualized segments belong to the descending aorta (25 to 40 cm from the incisors). In this group of patients the lipid levels did not seem to be a preponderant factor in aortic atherosclerosis. The most important factors were age for atherosis and BP for sclerosis.

[Changes in regional wall contractility induced by effort in women with normal coronary angiography --report of a clinical case]

The diagnosis of coronary artery disease in women has been thought to be more difficult than in men, owing to the lower overall prevalence of disease in women, as well as more subtle clinical presentations and unspecific changes in ST segment. The authors report a clinical case of a 61-year old woman, with low cardiovascular risk and history of atypical chest pain and a positive treadmill exercise test on the inferior leads. She did an exercise echocardiogram that revealed severe hypokinesis on the anterior wall and septum with late normalization. The patient was submitted to a coronary angiography that revealed normal arteries. An echocardiogram with hyperventilation was later performed and showed the same ischemic changes as exercise did, on the inferior leads but no regional wall motions abnormalities occurred. The patient is currently asymptomatic under calcium antagonist treatment.

[Plasma total anti-oxidant status in young survivors of myocardial infarction]

Free oxygen radicals are involved in the endothelial lesion process which leads to the formation of the atheroma plaque and thrombosis. There is some evidence that antioxidant therapy may be beneficial in coronary heart disease prevention. Our objective was to study the plasma total anti-oxidant status in young survivors of acute myocardial infarction.

POPULATION

23 patients, mean age 35.2 years (22-40) admitted for acute myocardial infarction from January 1995 to June 1998 (20 males).

RISK FACTORS

Tobacco smoking 22/23, systemic arterial hypertension 4/23, hypercholesterolemia 17/23, positive family history for coronary heart disease 5 patients, previous history of angina 4 patients, none of these patients had diabetes mellitus. The location of the infarct was anterior in 12 patients, inferior in 10 patients and non-Q wave in one patient. Blood samples were drawn after overnight fasting and the plasma total antioxidant status (TAS) was determined by a colorymethric method (Trolox equivalent). The mean time elapsed since the acute myocardial infarction until sample collection was 16.5 +/- 10.7 months.

RESULTS

18 patients had low TAS values, mean 1.23 +/- 0.11 mmol/L (below the reference values: 1.3-1.77 mmol/L).

CONCLUSIONS

In this group of patients, the plasma total antioxidant capacity was globally decreased, which may constitute a risk factor for coronary heart disease.

[Abciximab (ReoPro) in primary angioplasty]

The aim of the study was to evaluate the efficacy and safety of abciximab (ReoPro) in primary percutaneous transluminal coronary angioplasty (P.T.C.A.) in patients with myocardial infarction (M.I.). From June 96 to October 97, 16 patients with a mean age of 58 +/- 12 years, 86% males, with myocardial infarction (less than 12 hours of pain) were treated with ReoPro during P.T.C.A. The infarction was anterior in seven patients (44%), inferior in eight patients (50%) and non-Q wave in one patient (6%). Nine patients (47%) had a previous history of angina or myocardial infarction. The mean time from onset of symptoms to hospital arrival was 306 +/- 370 min and the mean time between hospital admission and the beginning of the procedure was 79 +/- 86 min. P.T.C.A. was performed on the anterior descending artery and right coronary in 44% and 56%, respectively. The success rate was 94%. Stents were used in 31%. In patients with angiographic success, we obtained TIMI III flow in 14 patients and TIMI II in one patient. No complications arose during P.C.T.A; no significant changes in platelets or hemoglobin were observed after the procedure. In this group of patients, one case of hematoma was found at the site of puncture with no need for transfusion. During hospitalization, no major coronary events were found. During the follow-up of 10.5 +/- 4.9 months, one patient died after non cardiac surgery and one patient was submitted to coronary artery bypass graft; there was no reinfarction nor new P.T.C.A.

CONCLUSIONS

In our experience with ReoPro during direct angioplasty, we obtained good immediate and long term results, with no significant bleeding complications.

[Is the stress test useful in the detection of post-angioplasty restenosis?]

Restetenosis is still the greatest limitation of coronary angioplasty (PTCA). The systematic use of ergometry (PE) with the objective of identifying restenosis is controversial and, namely, the ACC/AHA does not recommend its routine use. Our objective was to conduct a retrospective study of the use of PE when performed late (3 to 6 months) for the detection of restenosis. As a protocol, our group performed "late" PE on all the patients without contraindications, the patients with positive ergometry or CCS class II-IV angor submitted to angiographic control. Between January 1996 and July 1997, 121 patients (pts) were submitted to PTCA. Our study population was composed of patients submitted to complete revascularisation with follow-up in our centre: 59 pts (49%) with an average age of 58 +/- 12 years, 82% male. Eighty-three percent of the pts had revascularisation in a context of unstable angina, 10% in the acute phase of myocardial infarction and 7% due to chronic angina. Stents were implanted in 42% of the pts. In the follow-up after six months, 7 pts complained of CCS class II or III angor. The ergometry showed positive electrocardiographic criteria in 11 pts (18.6%). All pts with angor had positive PE. All these pts were submitted to angiographic control; restenosis (residual stenosis equal to or above 50%) was observed in all the patients who complained of angor (100% positive predictive value); restenosis occurred in 9 pts with positive ergometry (82% positive predictive value). In asymptomatic pts, PE indicated 2 pts with restenosis (2/59-3.4%) and two false positive (2/11-18%). At six months, PE detected 22% of the pts with restenosis. In conclusion, complete post-revascularisation angor due to coronary angioplasty has a higher positive predictive value than ergometry. However, the stress test, performed systematically, can identify an additional percentage of pts with restenosis with an acceptable percentage of false positives.

[Direct coronary angioplasty versus thrombolysis in the acute phase of myocardial infarction--inpatient outcome]

Both thrombolysis and percutaneous transluminal coronary angioplasty (PTCA) are effective methods for the treatment of acute myocardial infarction (AMI). In our centre we perform primary PTCA during the available schedule of the hemodynamics laboratory. In this article we compare the predischarge evolution of patients submitted to each therapeutic procedure. From January 1996 to June 1997, 298 patients were admitted with the diagnosis of AMI. Eighty-four patients (28%) were thrombolysed (TB group) and 30 patients (10%) underwent primary PTCA (PTCA group). There were no significant differences among the two groups concerning demographic characteristics: age (61 +/- 13--TB and 59 +/- 12 years--PTCA); sex (male 81%--TB; 83%--PTCA), risk factors and previous cardiac history. The mean time since the onset of symptoms until arrival at the hospital was 156 +/- 156 minutes for TB and 202 +/- 210 minutes for PTCA (p < 0.02). The delay since admission until the beginning of treatment was 100 +/- 88 minutes for TB and 119 +/- 142 minutes for PTCA. The primary success rate of PTCA was 94% and there were no complications during the procedure. During the hospital stay, 12 patients developed post-infarction angina in the TB group and two patients in the PTCA group; in 15 patients of the TB group a revascularization procedure was performed (surgery in 5 and PTCA in 10 patients); one patient suffered reinfarction in the TB group. Two patients of the TB group (2.4%) had intracranial hemorrhage; the in-hospital mortality was 9.5% in the TB group and 3.3% in the PTCA (p < 0.001). The mean in-hospital stay was 11 +/- 5.6 in the TB group and 7.8 +/- 2.5 days in the PTCA group (p = 0.055). In our experience, primary PTCA in AMI appeared to be a safe procedure with lower occurrence of coronary events and hemorrhagic complication, with an earlier hospital discharge when compared to thrombolysis.