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Our results show significant and independent influence of the GUSTO-1 trial on the use of recombinant tissue plasminogen activator in acute myocardial infarction in Germany. This influence started soon after the publication of the trial and was not restricted to subgroups who benefitted most from recombinant tissue plasminogen activator.

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BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) is widely used, but no quality control has been systematically performed as yet. METHODS: A registry of all PTCA procedures has been established since October 1992 for the majority of the German community hospitals performing PTCA, representing about one third of all PTCA activity in Germany. Baseline demographic data, indication for PTCA, primary success and in-hospital clinical events were recorded. Each centre was visited at regular intervals to assure completeness and reliability of the data. RESULTS: Of 52453 procedures performed from October 1992 to December 1994 the catheter laboratory and discharge forms were 99.7% and 98.1% complete, respectively. In 85.9% a single lesion was dilated per procedure, but 48.7% of the patients had multivessel disease. The success rate was 66.5% in complete occlusions (residual stenosis < 70%) and 91.2% in non-occluded vessels (residual stenosis < 50%). Abrupt vessel closure occurred in 3.4%, of which 77.5% could be recanalized by repeat intervention. In procedures not done for acute myocardial infarction, the in-hospital mortality was 0.52%, the procedure-related mortality 0.37%. In 3.02% of all patients a severe complication occurred (procedure-related death, myocardial infarction or emergency bypass surgery). CONCLUSION: Complete recording of all PTCA procedures is feasible even on a nationwide basis. This is a pre-requisite for continuous quality control. The reporting of the procedures by itself very probably, has an impact on the quality which is, however, not measurable quantitatively.

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The purpose of this investigation was to define cardioversion success rates, frequency of complications of cardioversion, and current treatment practices in elderly patients (aged > or = 65 years) with atrial fibrillation (AF). The results were compared with those in younger patients (aged < 65 years). The investigation was a prospective multicenter observational study with 61 participating cardiology clinics. Consecutive patients in whom cardioversion of AF was planned had to be prospectively registered. Of 1,152 patients registered, 570 (49.5%) were < 65 years old (group 1) and 582 (50.5%) were > or = 65 years (group 2). The overall success rate of cardioversion on an intention-to-treat basis was 76.1% in group 1 and 72.7% in group 2 (p = 0.18). In multivariate analysis, left atrial size and New York Heart Association functional class before cardioversion were identified as predictors of success (p < 0.001, respectively; p = 0.025). These clinical factors were not equally distributed between the age groups: Left atrial size was larger in the elderly than in younger patients (44.0 +/- 6.4 mm vs 42.8 +/- 6.4 mm; p = 0.006) and a New York Heart Association functional class > or = II was more prevalent in group 2 than in group 1 (48.6% vs 29.6%; p < 0.001). The overall complication rates were not significantly different between the 2 groups (4.2% in group 1 vs 5.3% in group 2; p = 0.37). The frequency of patients who were adequately anticoagulated for cardioversion was 56.9% in age group 1 and 39.6% in age group 2 (p < 0.001). In chronic AF the same trend for age-dependent underuse of anticoagulation was observed. Age itself was not a predictor of cardioversion success and did not predispose to higher complication rates. Therefore, cardioversion should be considered in older patients with the same criteria and emphasis as in younger patients. Anticoagulation and antithrombotic medication is underused for cardioversion and in treating chronic AF, especially in elderly patients.

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BACKGROUND: Adjunctive therapy for thrombolysis in acute myocardial infarction consists of platelet inhibition with aspirin and thrombin inhibition with heparin. Thrombin inhibition may be improved by the use of hirudin as indicated by experimental and phase II clinical studies. The randomized, double-blind phase III r-Hirudin for Improvement of Thrombolysis study (HIT III) compared a recombinant hirudin (HBW 023) with heparin. The primary end point was the incidence of death or reinfarction. METHODS AND RESULTS: Seven thousand patients with acute myocardial infarction and a duration of symptoms of less than 6 hours were to be randomized to receive intravenous heparin (70 IU/kg body wt bolus and 15 IU.kg-1.h-1) or hirudin (0.4 mg/kg body wt bolus and 0.15 mg.kg-1.h-1) infused over 48 to 72 hours and adjusted to an activated partial thromboplastin time of 2 to 3.5 times baseline values. In a pilot phase, 1000 patients receiving front-loaded alteplase for thrombolysis were to be recruited by 93 German centers. After enrollment of 302 patients, the trial was stopped after an increased rate of intracranial bleeding was observed in the hirudin group (5 of 148, 3.4%) compared with the heparin group (0 of 154). The overall stroke rate was 3.4% in the hirudin group and 1.3% in the heparin group. Other major bleeding occurred in five versus three patients and ventricular rupture occurred in three versus one patient in the hirudin and heparin groups, respectively. There were 19 in-hospital deaths, with 13 of them from the hirudin group. CONCLUSIONS: Although the number of patients was too small for a definite benefit-risk assessment, at the dosage tested, hirudin in combination with front-loaded alteplase and aspirin may be associated with an increased rate of intracranial hemorrhage. Our findings are consistent with the observations of the GUSTO-II and TIMI-9 trials, where higher doses of another recombinant hirudin were used. Therefore, the therapeutic range of hirudin as an adjunct to thrombolysis may be smaller than previously thought, and reappraisal of dose finding should be considered.

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An improved guiding catheter (IGC) for PTCA is presented. The IGC's distal tip is formed into a slit. This provides two advantages: 1) Via the proximal portion of the slit, positioned in the sinus of Valsalva, coronary perfusion is assured. With the IGC the flow is twice as great in vitro as with a guiding catheter with two sideholes. Since blood pressure is measured at the point of entry into the coronary artery, coronary flow can be reliably monitored through the pressure curve. 2) Positioned in the left main stem, the guide wire and the balloon catheter can be lead out of the slit in any chosen direction, with the position of the IGC remaining stable and both major branches being well perfused. The IGC was used in the treatment of 90 patients with good results and without complications.

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Endomyocardial biopsies were taken from the right ventricular aspect of the interventricular septum in three patients with hypertrophic cardiomyopathy and were subjected to electronmicroscopical examination. Longitudinal sections confirmed already well-established findings. In the transverse sections disarray in the arrangement of the actin filaments and expansion of the myosin lattice, indicating clear overcontraction, were observed. The number of actin filaments varied from seven to 14 per hexagon; a number exceeding 12, however, was found in only one case. From our findings we conclude that overcontraction leads to a progressive deviation of the action filaments during systole caused by double overlap. The majority of these mechanisms results in a "self-impeding contraction" of the fibres. Functionally the excess of actin filaments may provide a balance between the unequal forces of contraction.

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Seven patients with acute anterior myocardial infarction were treated with a betablocker (Pindolol 0.1-0.2 mg i.v.). The goal of the study was to determine the course of the ischemic ST elevation by means of precordial Ecg mapping (sigma-ST). Within 20 min a reduction of of sigma-ST of 23% p less than 0.05 and of the heart rate of 10% p less than 0.05 was noticed. The mean arterial pressure remained constant. In one case the heart rate rose, so did the sigma-ST. -Beside heart rate reduction a competitive effect of the betablocker against myocardial catecholamines in the ischemic area may lead to these results.

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After admission to the Coronary Care Unit 101 patients suffering from proved myocardial infarction were inquired about their prehospital phase. In the near future of the acute infarction the patients consulted their doctors more frequently. 73% had prodromi. The longest section of the prehospital phase was caused by the patient's decision time and the time between the call for help and the arrival at the hospital. However the transportation time was only 5% of the prehospital phase. Smoker's decision time was half that of non-smokers. Patients younger than 50 years had a longer decision time than patients of other agegroups. There was no differences in the prehospital phase for different days of the week, but the prehospital phase was longer at night than by day. To shorten the prehospital phase probably the best way is to cut down the decision time by medical advice and public information. In the case of the community of Hannover the advantages of a mobile coronary care unit are questionable.

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