ABSTRACTS

Abstracts of the Scientific Meeting of the Netherlands Society of Cardiology (NWC) 25 April 2003, Okura Hotel, Amsterdam Paraflesesslon 1: Intervention Voorzitters: Dr. G.j Laarman, Dr. HR. Michels Current PTCA pratce and results In the Nethedancs: isght from the GENDER prject

W.R.P. Agema' , P.S. Monraatsl, RJ. de Winter2, RA. Tio3, P.A.F.M. Doevendans4, M.P.M. de Maate,A.H. Zwinderman2,A. van der Laarse'l, E.E. van der Wall, J.W. Jukemal,2. 'LUMC, Ltiden, 2ICIN, Utrecht, 3AMC, Amsterdam, 4AZG, Groningen, 5UMCU, Utrecht and TNO , Leiden.

Purpose: To document the practice of interventional cardiology and the clinical restenosis rates in an unselected population of patients in the pre-drug eluting stent era and to provide a perspective for the need of these new devices. Methods: The Genetic DEterminants of Restenosis (GENDER) project is a prospective cohort study of 3000 patients after successful PTCA (less than 30% stenosis) in 4 academic tertiary referral centers for interventional cardiology in the Netherlands. Patients with acute myocardial infarction (MI) were exduded. Results: 3000 patients (age 62±11 yrs) were followed for 10.6±3.7 months. Of them 858 (25.6%) were female, 438 (14.6%) had diabetes and 1378 (45.9%) had multivessel disease. The majority was treated for stable angina, 967 (32.2%) had a non-ST elevation acute coronary syndrome. Multilesion PTCA was done in 768 (25.6%). Stenting was performed in 2888 (76.3%) and Ilb/IIIa inhibitors were used in 779 (26.0%). All stented patients received tidopidin/dopidogrel and ASA during at least 1 month after the procedure. Target vessel revascularisation during follow-up by either CABG or PTCAwas necessary in 309 patients (10.3%). Thirty-eight (1.3%) died ofcardiac disease, 20 (0.7%) of other causes. 28 (0.9%) suffered from MI attributable to the originally treated vessel. Overall a need for revascularisation, cardiac death or MI occurred in 378 patients (12.6%). Conclusion: In this unselected series of patients treated according to the current standards in the pre- drug eluting stent era clinical restenosis occurred in only 12.6%. A proper selection of patients that benefit from the new devices is warranted, since the vast majority is well treated with standard techniques and proper assignment of expensive new devices obviously is of importance for overall health care. Prehospta tris for prim anpla and aboted ST ebvation myocawd kInfarction EJP. Lamfers', P. Elsman', TEH. Hooghoudt', A. Schut', DP. Hertzberger', F. Zijlstra2, E. Boersma3, FWA. Verheuge4. 'Canisius Wilhelmina Hospital Nijmegen. 2Cardiology Hospital De Weezenlanden Zwolle, 3Cardiology Thorax Heart Center Rotterdam, 4Cardiology UMC StRadboud Nijmegen.

Backgrund: Previous reports have shown a three times higher occurrence ofaborted ST elevation myocardial infarction (STEMI) in patients treated by prehospital thrombolysis in comparison to in-hospital treatment. Prehospital infarct triage with primary angioplasty (PCI) has reduced symptom-to-balloon times considerably. Therefore we studied the incidence of abortion of myocardial infarction with this strategy. Methods: Atotal of 545 ptswere thrombolysed for STEMI in the cities ofRotterdam and Nijmegen,, and were compared with 236 pts treated with PCI after prehospital triage in Zwolle. AU pts were treated with nitroglycerin s.l and aspirin. Pts with prehospital triage for PCI were treated with heparin before transport. Time to reperfusion is defined as symptom to balloon time in primary angioplasty or symptom to thrombolysis time plus 90 minutes in prehospital thrombolysis. Abortion of STEMI is defined by resolution of characteristic symptoms and ECG-

2

changes, combined with a rise ofcardiac enzymes less than 2 times normal value. Results: (Table) Basic characteristics ofpts (age, sex, anterior infarction, diabetes, Killip at presentation) were not significantly different in both groups. Abortion ofSTEMI and 30-day mortality is comparable in both groups. Time to treatment was an independent variable for the incidence ofabortion ofSTEMI in both groups, using a stepwise regression analysis.

Time to reperfusion, median, minutes Aborted Ml (%) Haemorrh stroke (%) 30-day mortality

PrehosptalW

Primary

thrombolysis

angoplasty

n=545 180 87 (16.0) 10 (1.8) 38 (7.0)

n=236 170 26(11.0) 0 10 (4.2)

Conclusion: Prehospital triage for primary angioplasty results in a similar reperfusion time as prehospital thrombolysis. The incidence of aborted myocardial infarction is the same, but primary angioplasty seems to be safer. Long-tenr clnical outcom of ST-egment elvai myocada Ifartion patients wh end without diabetes melltus In the Zwolle trl JRTimmer, JPS Henriques, JCC van der Horst, KThomas, HJG Bilo, JCA Hoorntje, F Zijlstra, for the Zwolle Myocardial Infarction Study Group. Isala Klinieken, locatie Weezenlanden, Zwollc.

Purpose: We sought to compare long term survival after ST segment elevation myocardial infarction (STEMI) in patients with and without diabetes mellitus (DM) treated with primary percutaneous coronary intervention (PCI) or thrombolytic therapy. Background. DM is an adverse prognostic factor after STEMI. However, there is limited information about long term clinical outcome in STEMI patients with DM treated with PCI or thrombolysis. Methods: Patients with STEMI (n=395) were randomized to treatment either with intravenous streptokinase or PCI. Mean follow up was 8±2 years. We studied long term mortality of patients with DM (n=32) and without DM (n=363) and the interaction with treatment regimen. Results: After 8 years, a total of 17 patients with DM (53%) died compared to 88 (24%) patients without DM (OR 3.5, p 1mm/year, of which 17 underwent elective aortic root replacement because of an aortic root diameter >50 mm. In these 20 patients ascending aortic distensibility was significantly lower compared to uncomplicated patients (2±1 vs. 3±1 103 mmHg ', respectively, p1 mm/year, of which 2 patients underwent intervention. In these 11 patients thoracic descending aortic distensibility was significantly lower compared to patients without descending aortic complications (2±1 vs. 4±2 10'3 mmHg ', respectively, p90%) patients. A LV systolic dysfynction was diagnosed in 57% of patients. With respect to medication usage, 87% received diuretics, 68% ACE-inhibitors, 32% beta-blockers, 50% cardiac glycosides, 25% calcium antagonists, and 7% spironolactone. Patients who were included in the Netherlands were comparable to patients included in Europe. Important differences were observed (i.e. age, gender, and systolic LV dysfunction) between the survey population and participants of randomised clinical trials. Condusion: Diagnostic procedures in heart failure patients were performed according to the guidelines, but fewer patients than expected were treated according to the guidelines as provided by the European Society of Cardiology. Considerable differences were observed between heart failure patients, as seen in clinical setting, and their counterparts in clinical trials.

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Is there a difference In resporne to cardiac resynchronkzatlon therapy In patents with lschemic versus IdipathIc dlated cardiomyopathy?

S.G. Molhoek, J.J. Bax, L. van Erven, M. Bootsma, P. Steendijk, E.E. van der Wall, M.J. Schalij. Department ofcardiology, Leiden University Medical Center, the Netherlands.

Background: Cardiac resynchronization therapy (CRT) is a new therapeutic option for patients with drug-refractory end-stage heart failure. However, 30% of patients do not respond to this therapy. It has been suggested that patients with idiopathic cardiomyopathy have a higher likelihood of response as compared to patients with ischemic cardiomyopathy. Accordingly, response and long-term survival after CRT was compared between patients with ischemic cardiomyopathy and idiopathic dilated cardiomyopathy. Methods: 74 patients with end-stage heart failure, NYHA class III-IV, LVEF120ms and LBBB received a biventricular pacemaker. At baseline and after 6 months CRT NYHA class, Minnesota Quality of life score, and 6-minute walldng distance were evaluated. Long-term follow-up was obtained up to 2 years. Results: 46% (n=34) had ischemic and 54% (n=40) idiopathic cardiomyopathy. The 6-months follow-up data are summarized in the Table. Of note, 65% of patients with idiopathic as compared to 71% ischemic cardiomyopathy improved .1 in NYHA class. Long-term follow-up

NYHA class - baseline - 6 months Minnesota Score - baseline - 6 months 6 min walking distance (m) - baseline - 6 months

lschemic

Idiopathic

P-value

3.1±0.4

3.2±0.4

2.2±0.7

2.3±0.9

0.333 0.364

39±17 26±15

43±16 33±17

0.309 0.054

305±137 422±133

258±146 362±159

0.181 0.103

Netherlands Heart Journal, Volume

11, Suppl. 1, May 2003

Abstracts

(14.2±7.8months) showed a comparable survival rate: 87.5% for patients with idiopathic as compared to 88.3% for ischemic cardiomyopathy. Conclusion: Clinical benefit and survival after CRT was similar in patients with idiopathic and ischemic cardiomyopathy. Stmctural atrial remodeling during atrial tachycardla Is related to a high ventricular rate and Independent of electrical remodellng

BA. Schoonderwoerd, J. Ausmal, H.J.G.M. Crijns', D.J. van Veldhuisen, M.P. van den Berg, E.H. Blaauw, I.C. van Gelder. Department ofCardiology, Thoraxcenter, University Hospital Groningen and CARIM, University Hospital Maastricht'. Introduction: Atrial structural and electrophysiologic changes occur during atrial tachycardia. The role of the high ventricular rate in these processes remains yet to be established. Methods: Six goats were subjected to 4 weeks ofrapid atrioventricular (AV) pacing with an atrial and ventricular rate of 240 bpm resulting in the development of congestive heart failure (CHF). In another 5 goats, AV block was created after which they were subjected to 4 weeks ofatrial pacing, also at 240 bpm while the ventricular rate was kept low and regular at 80 bpm (A-paced). Pacing was only interrupted for measurement ofatrial effective refractory periods (AERP) and right atrial diameter (RAD). After 4 weeks, the ultrastructure of both atria and ventricles was examined by light- and electron microscopy. The percentage of atrial extracellular matrix (%ECM) was measured. An additional 6 goats served as controls. Results: In both experimental groups AERP reached minimum values within 1 week in all goats. In the AV-paced group severe structural remodeling occurred both in the atria and ventricles. These included severe loss of sarcomeres, glycogen accumulation, disruption of sarcoplasmic reticulum, the appearance of numerous small mitochondria and nuclei with homogeneously distributed chromatin. In contrast, in the atria of A-paced goats structural changes were virtually absent. Only a redistribution of nuclear chromatin was observed. Also the ventricles did not show any changes. The ultrastructure was normal in control animals. %ECM was increased in AV-paced goats (29%) when compared to Apaced animals (18%) and controls (17%) (p140mmHg registered on 24 hour ambulatory blood pressure monitoring. Student's unpaired t-test was used to compare IMTC of normotensive and hypertensive post-coarctectomy patients and controls. Results: Carotid IMTC ofthe normotensive (0.58(0.13)mm) and hypertensive patients (0.61(0.14)mm) were significant different compared to controls (0.54(0.09)mm), both p