SummaryBackgroundExperimental evidence suggests that xanthine oxidase inhibitors can reduce myocardial oxygen consumption for a particular stroke volume. If such an effect also occurs in man, this class of inhibitors could become a new treatment for ischaemia in patients with angina pectoris. We ascertained whether high-dose allopurinol prolongs exercise capability in patients with chronic stable angina.Methods65 patients (aged 18–85 years) with angiographically documented coronary artery disease, a positive exercise tolerance test, and stable chronic angina pectoris (for at least 2 months) were recruited into a double-blind, randomised, placebo-controlled, crossover study in a hospital and two infirmaries in the UK. We used computer-generated randomisation to assign patients to allopurinol (600 mg per day) or placebo for 6 weeks before crossover. Our primary endpoint was the time to ST depression, and the secondary endpoints were total exercise time and time to chest pain. We did a completed case analysis. This study is registered as an , number ISRCTN 82040078.FindingsIn the first treatment period, 31 patients were allocated to allopurinol and 28 were analysed, and 34 were allocated to placebo and 32 were analysed. In the second period, all 60 patients were analysed. Allopurinol increased the median time to ST depression to 298 s (IQR 211–408) from a baseline of 232 s (182–380), and placebo increased it to 249 s (200–375; p=0·0002). The point estimate (absolute difference between allopurinol and placebo) was 43 s (95% CI 31–58). Allopurinol increased median total exercise time to 393 s (IQR 280–519) from a baseline of 301 s (251–447), and placebo increased it to 307 s (232–430; p=0·0003); the point estimate was 58 s (95% CI 45–77). Allopurinol increased the time to chest pain from a baseline of 234 s (IQR 189–382) to 304 s (222–421), and placebo increased it to 272 s (200–380; p=0·001); the point estimate was 38 s (95% CI 17–55). No adverse effects of treatment were reported.InterpretationAllopurinol seems to be a useful, inexpensive, well tolerated, and safe anti-ischaemic drug for patients with angina.FundingBritish Heart Foundation.

High-dose allopurinol regresses LVH, reduces LV end-systolic volume, and improves endothelial function in patients with IHD and LVH. This raises the possibility that allopurinol might reduce future cardiovascular events and mortality in these patients. (Does a Drug Allopurinol Reduce Heart Muscle Mass and Improve Blood Vessel Function in Patients With Normal Blood Pressure and Stable Angina?; ISRCTN73579730).

Mortality rates following PPCI were higher in elderly patients although remained acceptable. Invasively measured shock index before PPCI is the strongest independent predictor of long-term outcome in elderly patients. In addition, predictors of in-hospital mortality were similar across different age groups but differed significantly in relation to longer-term mortality.

Background: To assess safety of early discharge following primary percutaneous coronary intervention (PPCI) for STelevation myocardial infarction (STEMI). Methods and results: Retrospective analysis of prospectively collected data of 2448 STEMI patients treated with PPCI surviving to hospital discharge. Post-discharge all-cause mortality was reported at 1, 7, and 30 days and long-term follow up. A total of 1542 patients (63.0%) were discharged within 2 days of admission (early discharge group) and 906 patients (37.0%) after 2 days (late discharge group). In both groups, no deaths were recorded 1 day post discharge. The early and late discharge group mortality figures for 7 days were 0 and 4 patients (0.04%) and between 7 and 30 days were 11 (0.7%) and 11 patients (1.2%), respectively. During a mean follow up of 584 days, 178 patients (7.3%) died: 67 in the early discharge group (4.3%) and 111 in the late discharge group (12.3%). Conclusions: This exploratory, observational study demonstrates that discharging low-risk STEMI patients within 2 days following PPCI is safe. For providers of health care, early discharge can help to allay the cost of providing a 24-hour PPCI service and adds to the recognized benefits arising from PPCI.

This study of real-world, unselected STEMI patients demonstrates that in a large, well-staffed centre, PPCI outside routine-working hours is safe with no difference in outcome of in-hospital and long-term mortality compared with PPCI during routine-working hours.

This study of real-world, unselected STEMI patients demonstrates that thrombus aspiration during PPCI is associated with a significant reduction in mortality, especially in those with a short total ischaemic time. These findings support the use of thrombectomy during PPCI in this group of patients.

SUMMARYBackground: The prognostic value of admission heart rate (HR) on long-term mortality in ST-elevation myocardial infarction (STEMI) remains uncertain in the modern era of primary percutaneous coronary intervention (PPCI). This study aimed to assess the predictive value of admission HR on long-term mortality following PPCI and the influence of betablockers on postdischarge survival. Methods: Retrospective analysis of prospectively collected data on 2310 PPCI-treated STEMI patients at a regional tertiary center between March 2008 and June 2010. Results: Patients were classified according to admission HR into either low ( 70 beat per minute [bpm], n = 1015) or high HR group (>70 bpm, n = 1295). At a median follow-up of 559 days, all-cause mortality was 7.0% in the low HR group compared to 12.7% in the high-HR group. In the Cox proportional hazard model, adjusted for several confounders, the hazard ratio (95% confidence interval) for all-cause mortality in the high HR group was 1.59 (1.15-2.20; P = 0.005). Every 10-bpm increase in admission HR was associated with 17% increase in all-cause mortality. Beta-blockers on discharge was associated with a reduction in postdischarge mortality only in the high HR group (adjusted hazard ratio, 0.49 [0.31-0.77; P = 0.002]), but not in the low HR group (adjusted hazard ratio, 0.74 [0.37-1.49; P = 0.33]). Conclusions: Elevated admission heart rate in PPCI-treated STEMI patients is associated with long-term all-cause mortality. Beta blocker therapy improved postdischarge survival in patients with elevated admission heart rate.

HEART outperformed both TIMI and GRACE in overall discriminative capacity for 30-day MACE. Using a single contemporary cTn at presentation, a HEART score of ≤3 demonstrated sensitivity and NPV of ≥99.5% for 30-day MACE. These results reach the threshold for a safe discharge strategy but should be interpreted thoughtfully in light of other work.