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Background-Bleeding in patients undergoing percutaneous coronary intervention (PCI) is associated with increased morbidity, mortality, length of hospitalization, and cost. We identified baseline clinical characteristics associated with bleeding complications after PCI and developed a simplified, clinically useful algorithm to predict patient risk. Methods and Results-Data were analyzed from 302 152 PCI procedures performed at 440 US centers participating in the National Cardiovascular Data Registry. As defined by the National Cardiovascular Data Registry, bleeding required transfusion, prolonged hospital stay, and/or a drop in hemoglobin Ͼ3.0 g/dL from any location, including percutaneous entry site, retroperitoneal, gastrointestinal, genitourinary, and other/unknown location. Bleeding complications occurred in 2.4% of patients. From the best-fitting model consisting of 15 clinical elements associated with post-PCI bleeding in a random 80% training cohort, we developed a parsimonious risk algorithm. Predictors of bleeding included age, gender, previous heart failure, glomerular filtration rate, peripheral vascular disease, no previous PCI, New York Heart Association/Canadian Cardiovascular Society Functional Classification class IV heart failure, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and cardiogenic shock. The parsimonious model was validated in the remaining 20% of the population (c-statistic, 0.72) and in clinically relevant subgroups of patients. This simplified model was used to derive a clinical risk algorithm, with larger numbers corresponding with greater risk. In 3 categories, bleeding rates were greater in patients with higher estimates (Յ7, 0.7%; 8 to 17, 1.8%; Ն18, 5.1%). Conclusions-This Clinical Perspective on p 229 Methods Study PopulationA description of the NCDR has been published. 6,7 We used version 3.04 of the CathPCI database, which contains data on PCI procedures performed from January 1, 2004, to March 31, 2006 DefinitionsFull descriptions of the data element definitions for version 3.04 of the CathPCI registry are available online at https://www.accncdr.com/ webncdr/DefaultCathPCI.aspx. Bleeding is defined by the CathPCI registry as (1) occurring at percutaneous entry site, during or after catheterization laboratory visit until discharge, which may be external or a hematoma Ͼ10 cm for femoral, Ͼ5 cm for brachial, or Ͼ2 cm for radial access; (2) retroperitoneal; (3) gastrointestinal; (4) genitourinary; and (5) other/unknown origin during or after catheterization laboratory visit until discharge. All bleeding events required a transfusion, prolonged hospital stay, and/or a drop in hemoglobin Ͼ3.0 g/dL. PCI indication consisted of (1) elective; (2) urgent (required during same hospitalization to minimize further clinical deterioration, worsening or sudden chest pain, congestive heart failure, acute MI, anatomy, intra-aortic balloon pump, unstable angina with intravenous nitroglycerin, or angina at rest); (3) emergency (to procedure or in transit to the ...

Evaluation of atherosclerotic plaque composition and morphometry may yield insight into plaque biology and the mechanisms of plaque-associated thrombosis. Analysis of intravascular ultrasound radiofrequency (IVUS-RF) backscatter signal is one technology that provides in vivo assessment of both atherosclerotic plaque composition and morphometry. We summarize three different approaches to IVUS-RF and critique the studies using this technology. In addition, we address the potential application of IVUS-RF to assess vulnerable plaque.

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Abstract-To elucidate mechanisms by which left ventricular (LV) hypertrophy (LVH) increases the risk of atherosclerotic heart disease, we sought to determine whether LVH is independently associated with coronary artery calcium (CAC) and serum C-reactive protein (CRP) levels in the general population. The Dallas Heart Study is a population-based sample in which 2633 individuals underwent cardiac MRI to measure LV structure, electron beam CT to measure CAC, and measurement of plasma CRP. We used univariate and multivariable analyses to determine whether LV mass and markers of concentric LV hypertrophy or dilation were associated with CAC and CRP. Increasing quartiles of LV mass indexed to fat-free mass, LV wall thickness, and concentricity, but not LV volume, were associated with CAC in both men and women (PϽ0.001). After adjustment for traditional cardiovascular risk factors and statin use, LV wall thickness and concentricity remained associated with CAC in linear regression (PϽ0.001 for each). These associations were particularly robust in blacks. LV wall thickness and concentricity were also associated with elevated CRP levels (Pϭ0.001 for both) in gender-stratified univariate analyses, although these associations did not persist in multivariable analysis. In conclusion, concentric LVH is an independent risk factor for subclinical atherosclerosis. LVH is also associated with an inflammatory state as reflected in elevated CRP levels, although this relationship appears to be mediated by comorbid conditions. These data likely explain in part why individuals with LVH are at increased risk for myocardial infarction. , whether determined by the ECG 1-9 or echocardiogram, 6 -8,10 -18 has been associated with various adverse cardiovascular outcomes, including mortality, myocardial infarction, and heart failure. Although there has been considerable speculation as to why LVH is such an important marker of risk, 19,20 the basic mechanisms that predispose patients with LVH to develop atherosclerotic heart disease (ASHD) are not known. Previous hypotheses have included abnormalities in the coronary vasculature 21-25 or platelets, 26 increased blood viscosity, 27 and a prothrombotic state. 28 In addition to these factors, which may contribute to reduced myocardial oxygen supply, myocardial oxygen demand is also increased in patients with LVH. 20 Another simple explanation for the association of LVH and ASHD is that LVH reflects target organ damage from concomitant risk factors, such as hypertension, thus providing a noninvasive barometer of the extent of ASHD. The association of LVH with atherosclerosis in other vascular territories, for example, the carotid artery, 29 supports this hypothesis. There are scant data as to whether LVH is associated with the burden of coronary atherosclerosis as estimated by coronary artery calcium (CAC). 30 -32 Yet another emerging hypothesis is that LVH itself is a low-level inflammatory state, as has been suggested recently from animal 33 and human studies. 34,35 If this is the case, one co...

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world’s population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment–elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

The prevalence of coronary artery disease and STelevation myocardial infarction (STEMI) are increasing in India. Although recent publications have focused on improving preventive measures in developing countries, less attention has been placed on the acute management of STEMI. Recent policy changes in India have provided new opportunities to address existing barriers but require greater investment and support in the coming years.Coronary artery disease (CAD) is currently the most common, non-infectious disease in India and will affect over 65 million of its people by the year 2015. 1 One of the gravest complications of CAD is ST-elevation myocardial infarction (STEMI), a lifethreatening medical emergency that results from a sudden, occlusive thrombus in the coronary artery. When STEMI patients are treated promptly with reperfusion therapy, significant reductions in mortality and morbidity are possible. 2 3 Unfortunately, the overall use and quality of acute reperfusion therapy in India lags significantly behind North America and Europe.In this paper, we discuss the current state of STEMI care in India and argue for greater investment in acute reperfusion therapy. Although recent publications have focused appropriately on improving preventive measures for CAD in India, 4e6 less attention has been placed on the acute management of STEMI, or in particular, how 'systems of care' approaches, popularised in North America and Europe, may be implemented. 7 8 We specifically highlight recent policy changes that provide new opportunities to address existing barriers and briefly describe a 'real-world' example of a STEMI systems of care programme initiated in the southern Indian state of Tamilnadu.