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      Pre-Discharge Exercise Test for Evaluation of Patients with Complete or Incomplete Revascularization following Primary Percutaneous Coronary Intervention: A DANAMI-2 Sub-Study

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          Objectives: It is unclear whether the completeness of revascularization impacts on the prognostic value of an exercise test after primary percutaneous coronary intervention (PCI). Methods: The DANAMI-2 trial included patients with ST elevation acute myocardial infarction randomized to primary PCI or fibrinolysis. Of the 790 patients randomized to primary PCI, 572 performed an exercise test. Prospectively, 310 patients were classified as having complete and 216 as having incomplete revascularization. Primary endpoint was a composite of reinfarction and/or death. Results: Patients with incomplete revascularization had lower exercise capacity [6.5 (95% CI: 1.9–12.8) vs. 7.0 (95% CI: 2.1–14.0) METs, p = 0.004] and more frequently ST depression [43 (20%) vs. 39 (13%), p = 0.02] compared to patients with complete revascularization. ST depression was not predictive of outcome in either groups, while multivariable analyses showed that exercise capacity was predictive of reinfarction and/or death in patients with incomplete revascularization [hazard ratio = 0.71 (95% CI: 0.54–0.93), p = 0.012] or of death alone [hazard ratio = 0.56 (95% CI: 0.41–0.77), p = 0.0003], which was not found in patients with complete revascularization. Conclusions: Exercise capacity was prognostic of reinfarction and/or death in patients with incomplete revascularization, but not in completely revascularized patients. ST segment depression alone did not predict residual coronary stenosis or dismal prognosis.

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          Most cited references 13

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          Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the U.S. from 1990 through 1999

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            Danish multicenter randomized study on fibrinolytic therapy versus acute coronary angioplasty in acute myocardial infarction: rationale and design of the DANish trial in Acute Myocardial Infarction-2 (DANAMI-2).

            Randomized trials have indicated that primary coronary angioplasty performed in patients admitted directly to highly-experienced angioplasty centers offers certain advantages over intravenous fibrinolytic therapy. However, the large majority of patients with acute myocardial infarction are submitted to hospitals without a catheterization laboratory. This means that additional transportation will be necessary for many patients if a strategy of acute coronary angioplasty is to be introduced as routine treatment. The delay of treatment caused by transportation might negate (part of) the benefits of primary angioplasty compared to fibrinolytic therapy given immediately at the local hospital. The DANish trial in Acute Myocardial Infarction-2 (DANAMI-2) is the first large-scale study to clarify, in a whole community, which of the 2 treatment strategies is best. A total of 1900 patients with ST-elevation myocardial infarction are to be randomized: 800 patients will be admitted to invasive hospitals and 1100 patients will be admitted to referral hospitals. Half of the 1100 patients admitted to referral hospitals will immediately be transferred to an invasive center to be treated with primary angioplasty. If acute transfer from a local hospital to an angioplasty center is the superior strategy, primary angioplasty should be offered to all patients as routine treatment on a community basis.
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              A metaanalysis of predischarge risk stratification after acute myocardial infarction with stress electrocardiographic, myocardial perfusion, and ventricular function imaging.

              We assessed the relation of abnormal predischarge non-invasive test results to outcomes in postmyocardial infarction patients. We included series published from 1980 to 1995 containing only myocardial infarction patients, enrolling most patients after 1980, testing within 6 weeks of infarction, having follow-up rates > 80%, and having 2 x 2 frequency outcome rates for test results, that were the latest of multiple reports. Sensitivity, specificity, and predictive values were calculated for test results for 1-year outcomes (cardiac death, cardiac death or reinfarction). Univariable and summary odds were calculated for test results. Reports (n = 54) included a total of 19,874 patients and were primarily retrospective (76%) and small series (35% of reports included < 5 deaths). One-year mortality ranged from 2.5% for pharmacologic stress echocardiography to 9.3% for exercise radionuclide angiography. Positive predictive values for most noninvasive risk markers were < 0.10 for cardiac death and < 0.20 for death or reinfarction. Electrocardiographic, symptomatic, and scintigraphic risk markers of ischemia (ST-segment depression, angina, a reversible defect) were less sensitive (< or = 44%) for identifying morbid and fatal outcomes than markers of left ventricular dysfunction or heart failure (exercise duration, impaired systolic blood pressure response, and peak left ventricular ejection fraction). The positive predictive value of predischarge noninvasive testing is low. Markers of left ventricular dysfunction appear to be better predictors than markers of ischemia. Limitations of the literature-small samples and widely varying event rates-impede our ability to discern the accuracy of pre-discharge noninvasive testing. More rigorous, controlled trials are required to elucidate the relative value of these tests for risk stratification.

                Author and article information

                S. Karger AG
                February 2008
                28 August 2007
                : 109
                : 3
                : 163-171
                Department of Cardiology, The Heart Center, Copenhagen University Hospital, Copenhagen, Denmark
                106677 Cardiology 2008;109:163–171
                © 2007 S. Karger AG, Basel

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                Page count
                Figures: 1, Tables: 5, References: 23, Pages: 9
                Original Research


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