In our small, pilot trial, administration of cyclosporine at the time of reperfusion was associated with a smaller infarct by some measures than that seen with placebo. These data are preliminary and require confirmation in a larger clinical trial.

Background-In animal models, brief periods of ischemia performed just at the time of reperfusion can reduce infarct size, a phenomenon called postconditioning. In this prospective, randomized, controlled, multicenter study, we investigated whether postconditioning may protect the human heart during coronary angioplasty for acute myocardial infarction. Methods and Results-Thirty patients, submitted to coronary angioplasty for ongoing acute myocardial infarction, contributed to the study. Patients were randomly assigned to either a control or a postconditioning group. After reperfusion by direct stenting, control subjects underwent no further intervention, whereas postconditioning was performed within 1 minute of reflow by 4 episodes of 1-minute inflation and 1-minute deflation of the angioplasty balloon. Infarct size was assessed by measuring total creatine kinase release over 72 hours. Area at risk and collateral blood flow were estimated on left ventricular and coronary angiograms. No adverse events occurred in the postconditioning group. Determinants of infarct size, including ischemia time, size of the area at risk, and collateral flow, were comparable between the 2 groups. Area under the curve of creatine kinase release was significantly reduced in the postconditioning compared with the control group, averaging 208 984Ϯ26 576 compared with 326 095Ϯ48 779 (arbitrary units) in control subjects, ie, a 36% reduction in infarct size. Blush grade, a marker of myocardial reperfusion, was significantly increased in postconditioned compared with control subjects: 2.44Ϯ0.17 versus 1.95Ϯ0.27, respectively (PϽ0.05). Conclusions-This

Background-We previously demonstrated that ischemic postconditioning decreases creatine kinase release, a surrogate marker for infarct size, in patients with acute myocardial infarction. Our objective was to determine whether ischemic postconditioning could afford (1) a persistent infarct size limitation and (2) an improved recovery of myocardial contractile function several months after infarction. Methods and Results-Patients presenting within 6 hours of the onset of chest pain, with suspicion for a first ST-segment-elevation myocardial infarction, and for whom the clinical decision was made to treat with percutaneous coronary intervention, were eligible for enrollment. After reperfusion by direct stenting, 38 patients were randomly assigned to a control (no intervention; nϭ21) or postconditioned group (repeated inflation and deflation of the angioplasty balloon; nϭ17). Infarct size was assessed both by cardiac enzyme release during early reperfusion and by 201 thallium single photon emission computed tomography at 6 months after acute myocardial infarction. At 1 year, global and regional contractile function was evaluated by echocardiography. At 6 months after acute myocardial infarction, single photon emission computed tomography rest-redistribution index (a surrogate for infarct size) averaged 11.8Ϯ10.3% versus 19.5Ϯ13.3% in the postconditioned versus control group (Pϭ0.04), in agreement with the significant reduction in creatine kinase and troponin I release observed in the postconditioned versus control group (Ϫ40% and Ϫ47%, respectively). At 1 year, the postconditioned group exhibited a 7% increase in left ventricular ejection fraction compared with control (Pϭ0.04). Conclusions-Postconditioning affords persistent infarct size reduction and improves long-term functional recovery in patients with acute myocardial infarction.

No abstract

MD; for the Comparison of Angioplasty and Prehospital Thrombolysis In acute Myocardial infarction (CAPTIM) Investigators*Background-CAPTIM was a randomized trial comparing prehospital thrombolysis with transfer to an interventional facility (and, if needed, percutaneous intervention) with primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI). Because the benefit of thrombolysis is maximal during the first 2 hours after symptom onset, and because prehospital thrombolysis can be implemented earlier than PCI, this analysis studied the relationship between the effect of assigned treatment and the time elapsed from symptom onset. Methods and Results-Randomization within 2 hours (nϭ460) or Ն2 hours (nϭ374) after symptom onset had no impact on the effect of treatment on the 30-day combined primary end point of death, nonfatal reinfarction, and disabling stroke. However, patients randomized Ͻ2 hours after symptom onset had a strong trend toward lower 30-day mortality with prehospital thrombolysis compared with those randomized to primary PCI (2.2% versus 5.7%, Pϭ0.058), whereas mortality was similar in patients randomized Ն2 hours (5.9% versus 3.7%, Pϭ0.47). There was a significant interaction between treatment effect and delay with respect to 30-day mortality (hazard ratio 4.19, 95% CI 1.033 to 17.004, Pϭ0.045). Among patients randomized in the first 2 hours, cardiogenic shock was less frequent with lytic therapy than with primary PCI (1.3% versus 5.3%, Pϭ0.032), whereas rates were similar in patients randomized later. Conclusions-Time from symptom onset should be considered when one selects reperfusion therapy in STEMI.Prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 hours after symptom onset.

Cyclosporine used at the moment of acute myocardial infarction reperfusion persistently reduces infarct size and does not have a detrimental effect on LV remodeling. These results are preliminary and must be supported by further studies. (Ciclosporin A and Acute Myocardial Infarction; NCT00403728).

The 5-year follow-up is consistent with the 30-day outcomes of the trial, showing similar mortality for primary percutaneous coronary intervention and a policy of pre-hospital lysis followed by transfer to an interventional center. In addition, for patients treated within 2 h of symptom onset, 5-year mortality was lower with pre-hospital lysis.

CARDIAC IMAGINGC oronary CT angiography (CCTA) is currently recommended for the assessment of many cardiovascular diseases, including coronary artery disease (CAD) evaluation (1). CCTA is particularly important for its high negative predictive value for CAD in a low-and intermediaterisk acute chest pain population, with a high sensitivity and specificity for CAD in a low-and intermediate-risk chronic coronary syndrome population (2-5). This had been made possible by the recent technical evolution of the CT systems and the existence of large-scale validation cohort studies (6,7). However, conventional CCTA still has a limited spatial resolution and soft-tissue contrast, which impairs its diagnostic performance for small arteries (ie, ,2 mm) and high-contrast (eg, stent, calcification) and low-contrast (eg, noncalcified plaque) tasks, and carries the risks of relatively high x-ray dose delivery.Over the past 5 years, photon-counting CT (PCCT) technology has emerged in the field of CT imaging. Compared with conventional CT, this new modality has better spatial resolution and soft-tissue contrast and reduced noise, blooming, and beam-hardening artifacts (8). This is because of new energy-resolving detectors, called photon-counting Background. Spatial resolution, soft-tissue contrast, and dose-efficient capabilities of photon-counting CT (PCCT) potentially allow a better quality and diagnostic confidence of coronary CT angiography (CCTA) in comparison to conventional CT. Purpose:To compare the quality of CCTA scans obtained with a clinical prototype PCCT system and an energy-integrating detector (EID) dual-layer CT (DLCT) system. Materials and Methods:In this prospective board-approved study with informed consent, participants with coronary artery disease underwent retrospective electrocardiographically gated CCTA with both systems after injection of 65-75 mL of 400 mg/mL iodinated contrast agent at 5 mL/sec. A prior phantom task-based quality assessment of the detectability index of coronary lesions was performed. Ultra-high-resolution parameters were used for PCCT (1024 matrix, 0.25-mm section thickness) and EID DLCT (512 matrix, 0.67-mm section thickness). Three cardiac radiologists independently performed a blinded analysis using a five-point quality score (1 = insufficient, 5 = excellent) for overall image quality, diagnostic confidence, and diagnostic quality of calcifications, stents, and noncalcified plaques. A logistic regression model, adjusted for radiologists, was used to evaluate the proportion of improvement in scores with the best method.Results: Fourteen consecutive participants (12 men; mean age, 61 years 6 17) were enrolled. Scores of overall quality and diagnostic confidence were higher with PCCT images with a median of 5 (interquartile range [IQR], 2) and 5 (IQR, 1) versus 4 (IQR, 1) and 4 (IQR, 3) with EID DLCT images, using a mean tube current of 255 mAs 6 0 versus 349 mAs 6 111 for EID DLCT images (P , .01). Proportions of improvement with PCCT images for quality of calcification, stent, and non...