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Liu F, Guo Q, Xie G, Zhang H, Wu Y, Yang L. Percutaneous Coronary Intervention after Fibrinolysis for ST-Segment Elevation Myocardial Infarction Patients: An Updated Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0141855. [PMID: 26523834 PMCID: PMC4629904 DOI: 10.1371/journal.pone.0141855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/14/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI), fibrinolysis and the combination of both methods are current therapeutic options for patients with ST-segment elevation myocardial infarction (STEMI). METHODS We searched PubMed, EMBASE, Google scholar and Cochrane Controlled Trials Register for randomized controlled trials (RCTs) evaluating the efficacy and safety of PCI after fibrinolysis within 24 hours, which was compared with primary PCI alone and ischemia-guided or delayed PCI. Meta-analysis was conducted using Review Manager 5.30 following the methods described by the Cochrane library. RESULTS A total of 16 studies including 10,034 patients were enrolled. As compared with primary PCI alone group, the short-term mortality (5.8% vs 4.5%, RR 1.29, 95% confidence interval [CI] 1.00-1.65) and re-infarction rate (4.1% vs 2.7%, RR 1.46, 95%CI 1.05-2.03) were higher in the immediate PCI group (median/mean time ≤ 2 h after fibrinolysis). However, the short-term mortality and re-infarction rate showed no statistically significant differences in the early PCI group (2-24 hours after fibrinolysis). The rate of major bleeding events was higher both in the immediate PCI (6.3% vs 4.4%, RR 1.43, 95%CI 1.11-1.85) and the early PCI group (6.4% vs 4.4%, RR 1.46, 95%CI 1.03-2.06) as compared with primary PCI alone group. As compared with ischemia-guided or delayed PCI, early PCI was associated with significantly reduced re-infarction (2.4% vs 4.0%, RR 0.61, 95%CI 0.41-0.92) and recurrent ischemia (1.5% vs 5.3%, RR 0.29, 95%CI 0.12-0.70) at short-term. And the reduced re-infarction rate was also observed at long-term. CONCLUSIONS Early PCI after fibrinolysis, with a relatively broader time for PCI preparation, can bring the similar effects with primary PCI alone and is better than ischemia-guided or delayed PCI in STEMI patients with symptom onset < 12 h who cannot receive timely PCI. However, immediate PCI after fibrinolysis is detrimental.
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Affiliation(s)
- Feng Liu
- Department of Postgraduate, Third Military Medical University, Chongqing, China
- Department of Postgraduate, Second Military Medical University, Shanghai, China
| | - Qinglong Guo
- Department of Postgraduate, Second Military Medical University, Shanghai, China
| | - Guoqiang Xie
- Department of Postgraduate, Second Military Medical University, Shanghai, China
| | - Han Zhang
- Department of Postgraduate, Second Military Medical University, Shanghai, China
| | - Yaxi Wu
- Department of Cardiology, Kunming General Hospital of Chengdu Military Area, Yunnan, China
- Department of Postgraduate, Kunming Medical University, Yunnan, China
| | - Lixia Yang
- Department of Cardiology, Kunming General Hospital of Chengdu Military Area, Yunnan, China
- * E-mail:
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Burns RJ, Gibbons RJ, Yi Q, Roberts RS, Miller TD, Schaer GL, Anderson JL, Yusuf S. The relationships of left ventricular ejection fraction, end-systolic volume index and infarct size to six-month mortality after hospital discharge following myocardial infarction treated by thrombolysis. J Am Coll Cardiol 2002; 39:30-6. [PMID: 11755283 DOI: 10.1016/s0735-1097(01)01711-9] [Citation(s) in RCA: 373] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We sought to relate left ventricular ejection fraction (EF), end-systolic volume index (ESVI) and infarct size (IS), as measured in a single randomized trial, to six-month mortality after myocardial infarction (MI) treated with thrombolysis. BACKGROUND These three prognostic indicators have never been compared in the same study group. METHODS Radionuclide angiographic and single-photon emission computed tomographic sestamibi measurements of IS were performed in 1,194 and 1,181 patients, respectively, of the 2,948 patients enrolled in the Collaborative Organization for RheothRx Evaluation (CORE) trial. Ejection fraction, ESVI and IS, as measured by central laboratories in these radionuclide substudies, were tested for their association with six-month mortality. RESULTS Ejection fraction (n = 1,137; p < 0.0001), ESVI (n = 945; p = 0.055) and IS (n = 1,164; p = 0.03) were all associated with six-month mortality. Each of these measurements was significantly correlated with the other two, regardless of MI location. In an "overlap" group of 753 patients (25.5% of the population; 13 deaths) in whom all three measurements were available, EF (p = 0.001) was a stronger predictor than ESVI (p = 0.005) or IS (p = 0.01). Neither of the other two measurements added independent prognostic information. The highest risk subgroup (EF < 30%) had an 11% six-month mortality, but comprised only 95 patients (8.3%). CONCLUSIONS Ejection fraction, ESVI and IS measurements performed one to two weeks after MI can each predict six-month mortality. Ejection fraction was superior to the other two measurements. However, this study had limited power to detect independent significance of ESVI or IS.
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Affiliation(s)
- Robert J Burns
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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Current and Practical Management of Acute Myocardial Infarction. J Thromb Thrombolysis 2000; 4:375-396. [PMID: 10639644 DOI: 10.1023/a:1008801500912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Affiliation(s)
- R G Favaloro
- Institute of Cardiology and Cardiovascular Surgery of the Favaloro Foundation, Buenos Aires, Argentina
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Taylor AJ, Meyer GS, Morse RW, Pearson CE. Can characteristics of a health care system mitigate ethnic bias in access to cardiovascular procedures? Experience from the Military Health Services System. J Am Coll Cardiol 1997; 30:901-7. [PMID: 9316516 DOI: 10.1016/s0735-1097(97)00271-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This study sought to investigate the independent effect of ethnicity on the utilization of invasive cardiac procedures after acute myocardial infarction (AMI). BACKGROUND The precise role of ethnicity in access to cardiovascular procedures is unknown, particularly because of difficulty in isolating ethnicity from financial and other socioeconomic factors. We conducted a retrospective analysis of the use of cardiac catheterization and coronary revascularization procedures after AMI in military health care beneficiaries. The Military Health Services System (MHSS) ensures equal access to care in an environment without financial incentives for procedural utilization; furthermore, socioeconomic differences between patients beyond ethnicity are minimized. METHODS Data were analyzed from the Civilian External Peer Review Program representing abstracted chart reviews from 125 military health care facilities worldwide for all patients (1,208 white; 233 nonwhite [155 black]) with the principal or secondary diagnosis of AMI from March to September 1993. RESULTS Rates of cardiac catheterization were similar in white and nonwhite patients (34.8 vs. 39.1%, p = 0.21). After controlling for age, gender, cardiovascular risk factors and AMI variables, including infarct size and other risk markers, there were no differences in the use of this procedure during the AMI admission in comparisons of white versus nonwhite patients (estimated odds ratio [OR] 0.96, 95% confidence interval [CI] 0.69 to 1.34) and white versus black patients (OR 1.19, 95% CI 0.80 to 1.78). However, white patients were significantly more likely than nonwhite patients to be "considered" for future cardiac catheterization (OR 1.77, 95% CI 1.19 to 2.61). Coronary revascularization within 180 days was not significantly affected by race in white versus nonwhite (OR 0.90, 95% CI 0.59 to 1.39) and white versus black patients (OR 1.11, 95% CI 0.65 to 1.89). Outcomes (30- and 180-day mortality and readmission rates) were similar for all race groups. CONCLUSIONS There is a limited relation between ethnicity and the use of invasive cardiac procedures in the MHSS. These data raise the promise that characteristics of a health care system can mitigate ethnic bias in medicine.
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Affiliation(s)
- A J Taylor
- Department of Medicine, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA.
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Affiliation(s)
- C I Pepine
- University of Florida College of Medicine, Division of Cardiovascular Medicine, Gainesville 32610-0277, USA
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Ryan TJ, Anderson JL, Antman EM, Braniff BA, Brooks NH, Califf RM, Hillis LD, Hiratzka LF, Rapaport E, Riegel BJ, Russell RO, Smith EE, Weaver WD. ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1996; 28:1328-428. [PMID: 8890834 DOI: 10.1016/s0735-1097(96)00392-0] [Citation(s) in RCA: 640] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- T J Ryan
- American College of Cardiology, Educational Services, Bethesda, MD 20814-1699, USA
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Kuntz KM, Tsevat J, Goldman L, Weinstein MC. Cost-effectiveness of routine coronary angiography after acute myocardial infarction. Circulation 1996; 94:957-65. [PMID: 8790032 DOI: 10.1161/01.cir.94.5.957] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Coronary angiography is indicated for many patients after acute myocardial infarction (AMI). There are a number of subgroups of AMI patients, however, for whom the indication for coronary angiography is not well established. METHODS AND RESULTS We developed a decision-analytic model for AMI in representative patient subgroups based on relevant clinical characteristics. The model estimates quality-adjusted life expectancy and direct lifetime costs for two strategies: coronary angiography and treatment guided by its results versus initial medical therapy without angiography. Decision tree chance node probabilities were estimated with the use of pooled data from randomized clinical trials and other relevant literature, costs were estimated with the use of the Medicare Part A database, and quality of life adjustments were derived from a survey of 1051 patients who had had a recent AMI. In our analysis, incremental cost-effectiveness ratios for coronary angiography and treatment guided by its result, compared with initial medical therapy without angiography, ranged between $17,000 and > $1 million per quality-adjusted year of life gained. Patient subgroups with severe postinfarction angina or a strongly positive exercise tolerance test (ETT) typically had cost-effectiveness ratios of < $50,000 per quality-adjusted year of life gained. In addition, most patient subgroups with a prior AMI had cost-effectiveness ratios of < $50,000 per quality-adjusted year of life gained, even with a negative ETT result. CONCLUSIONS In many patient subgroups after AMI, the cost-effectiveness of routine coronary angiography and treatment guided by its results compares favorably with other treatment strategies for coronary heart disease.
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Affiliation(s)
- K M Kuntz
- Section for Clinical Epidemiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Mruk JS, Zoldhelyi P, Webster MW, Heras M, Grill DE, Holmes DR, Fuster V, Chesebro JH. Does antithrombotic therapy influence residual thrombus after thrombolysis of platelet-rich thrombus? Effects of recombinant hirudin, heparin, or aspirin. Circulation 1996; 93:792-9. [PMID: 8641009 DOI: 10.1161/01.cir.93.4.792] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Thrombolysis to normal flow in patients with acute myocardial infarction preserves left ventricular function and decreases mortality. Failure of early reperfusion, reocclusion, or residual thrombus may be due to concurrent activation of the platelet-coagulation system. Thus, we hypothesized that the best concomitant antithrombotic therapy (recombinant [r]-hirudin, heparin, or aspirin) will maximally accelerate thrombolysis by r-tissue-type plasminogen activator (rTPA) and reduce residual thrombus. METHODS AND RESULTS Occlusive thrombi were formed in the carotid arteries of 29 pigs (by balloon dilatation followed by endarterectomy at the site of injury-induced vasospasm) and matured for 30 minutes before rTPA was started, with or without antithrombotic therapy. Thrombolysis was assessed with the use of angiography and measurement of residual thrombus. Pigs were allocated to one of five treatments: placebo, rTPA, rTPA plus r-hirudin, rTPA plus heparin, or rTPA plus intravenous aspirin. No placebo-treated pig reperfused. Two of six animals treated with rTPA alone reperfused compared with seven of seven animals treated with rTPA plus r-hirudin (reperfusion time, 33 +/- 10 minutes), six of seven animals treated with rTPA plus heparin (reperfusion time, 110 +/- 31 minutes), and two of six animals with rTPA plus aspirin. The activated partial thromboplastin time was prolonged in only the rTPA plus r-hirudin group (25 +/- 0.1 times baseline) and the rTPA plus heparin group (5.3 +/- 0.2 times baseline). Residual 111In-platelet and 125I-fibrin(ogen) depositions were lower in the heparin-treated group and lowest in the r-hirudin-treated group (heparin versus hirudin, respectively; incidence of residual macroscopic thrombus was six of six animals versus two of seven [P = .01]; 125I-fibrin(ogen), 170 +/- 76 versus 48 +/- 6 x 10(6) molecules/cm2 [P = .02]; 111In-platelets, 47 +/- 15 versus 13 +/- 2 x 10(6)/cm2, P = .10). No pigs developed spontaneous bleeding. CONCLUSIONS Thrombin inhibition with heparin or r-hirudin significantly accelerated thrombolysis of occlusive platelet-rich thrombosis, but only the best antithrombotic therapy (r-hirudin) eliminated or nearly eliminated residual thrombus.
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Affiliation(s)
- J S Mruk
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn, USA
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Miller TD, Christian TF, Hopfenspirger MR, Hodge DO, Gersh BJ, Gibbons RJ. Infarct size after acute myocardial infarction measured by quantitative tomographic 99mTc sestamibi imaging predicts subsequent mortality. Circulation 1995; 92:334-41. [PMID: 7634446 DOI: 10.1161/01.cir.92.3.334] [Citation(s) in RCA: 258] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND 99mTc sestamibi is a recently developed radioisotope that has been used to measure myocardium at risk and infarct size. The relation between these measurements and subsequent patient outcome has not yet been demonstrated. METHODS AND RESULTS Two hundred seventy-four consecutive patients with acute myocardial infarction underwent tomographic 99mTc sestamibi imaging on arrival at the hospital (to measure myocardium at risk before reperfusion therapy) and at hospital discharge (to measure the amount of salvaged myocardium and final infarct size). Defect size on the sestamibi images was quantified using a threshold value of 60% of peak counts from the circumferential count profile curves generated for five representative slices of the left ventricle. Patients were followed after hospital discharge to evaluate the association between final infarct size and subsequent mortality. The median defect size measured was 27% of the left ventricle at presentation to the hospital (range, 0% to 77%) and was 12% of the left ventricle at hospital discharge (range, 0% to 68%). Almost one half of the patients had a final infarct size of < or = 10%. The median amount of myocardium salvaged was 9% (range, -31% to 75%). During a median duration of follow-up of 12 months, there were 10 deaths (7 cardiac and 3 noncardiac) and 1 resuscitated out-of-hospital cardiac arrest. There was a significant association between infarct size and overall mortality (chi 2 = 8.66, P = .003) and cardiac mortality (chi 2 = 11.89, P < .001). Two-year mortality was 7% for patients whose infarct size was > or = 12% versus 0% for patients whose infarct size was < 12%. There also was a significant association between myocardium at risk and cardiac mortality (chi 2 = 6.87, P = .009). There was no association between myocardium at risk and overall mortality or between amount of myocardium salvaged and either overall mortality or cardiac mortality. CONCLUSIONS Larger infarct size measured by 99mTc sestamibi imaging after acute myocardial infarction is associated with increased mortality risk during short-term follow-up.
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Affiliation(s)
- T D Miller
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
Acute myocardial infarction, the leading cause of death in western society, has been the focus of more randomized clinical trial effort over the past decade than any other area of medicine. As a result of this worldwide effort, involving hundreds of thousands of patients with myocardial infarction, data have accumulated showing substantially lower mortality of acute myocardial infarction with simple interventions such as i.v. thrombolytic therapy, aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors. Emergency coronary angioplasty appears to be a suitable alternative to i.v. thrombolytic therapy in skilled centers. Several previously recommended therapies (routine i.v. lidocaine, calcium channel blockers, magnesium, nitrates) have not been proved to be life-saving. Whether routine coronary arteriography should be employed after myocardial infarction remains controversial, but it is generally accepted that patients with evidence of residual ischemia after infarction, either spontaneous or provoked by stress testing, should undergo prophylactic coronary revascularization.
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Affiliation(s)
- W J Rogers
- University of Alabama Medical Center, Birmingham 35294, USA
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Miller TD, Gersh BJ, Christian TF, Bailey KR, Gibbons RJ. Limited prognostic value of thallium-201 exercise treadmill testing early after myocardial infarction in patients treated with thrombolysis. Am Heart J 1995; 130:259-66. [PMID: 7631605 DOI: 10.1016/0002-8703(95)90438-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The purpose of this study was to determine the prognostic value of thallium-201 exercise treadmill testing performed early after myocardial infarction in patients treated with thrombolysis. A retrospectively identified group of 210 patients treated with thrombolytic therapy alone (n = 131) or with thrombolytic therapy and coronary angioplasty (n = 79) who underwent tomographic thallium exercise treadmill testing 9 +/- 6 days after infarction were followed up for a median of 21 months. There was a high prevalence of abnormalities on the thallium studies. One hundred thirty-nine (66%) patients had a high-risk scan, defined as redistribution in at least one segment, a defect outside the infarct zone, or increased pulmonary uptake. Thirty-six (17%) patients underwent early revascularization. In the remaining 174 patients, there were 30 initial cardiac events (1 cardiac death, 11 nonfatal recurrent myocardial infarctions, and 18 revascularization procedures performed > 3 months after the thallium study). No single exercise or thallium variable was predictive of outcome. At 2 years there were no differences in survival free of any cardiac event for patients with a high- or low-risk thallium scan treated with thrombolysis alone (high-risk scan 86% and low-risk scan 80%; p not statistically significant [NS]) or with both thrombolysis and coronary angioplasty (high-risk scan 80% and low-risk scan 77%; p NS). Postinfarction exercise thallium variables associated with poor outcome in the prethrombolytic era were not associated with an adverse outcome in patients who had been treated with thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Bolognese L. Risk stratification after myocardial infarction: targets and tools. Echocardiography 1995; 12:311-6. [PMID: 10150477 DOI: 10.1111/j.1540-8175.1995.tb00554.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The increasing use of thrombolytic therapy and coronary revascularization, either as acute therapy or early thereafter, has ushered in the "interventional era" of management of myocardial infarction (MI). This new scenario has at least two clear cut clinical implications. First, the cardiologist can intervene earlier to change the "natural history" of MI, not only to improve the immediate inhospital prognosis but also to prevent the development of those factors affecting the clinical outcome after discharge. Second, patients currently selected for predischarge evaluation are at lower risk for subsequent cardiac events. The critical management decision is with the majority of patients who have an uncomplicated MI. Two approaches may be applied to this large cohort to assess cardiac risk before hospital discharge. One method is the initial use of noninvasive tests reserving coronary angiography for patients with abnormal test results. The second approach comprises early cardiac catheterization in virtually all survivors. The routine use of angiography after MI does not appear to lead to an improved course compared to a more selective approach. Based on observation of an excellent 1-year outcome of patients in the conservative group of the large TIMI-2 and SWIFT trials, one could conclude that predischarge risk stratification by stress testing and clinical assessment has been empirically, albeit not experimentally, validated. On the other hand, if a noninvasive test proved to be highly predictive of subsequent cardiac events, the need for doing routine coronary angiography would in large part be obviated. Developing or refining such a test should take into account several caveats.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- L Bolognese
- Division of Cardiology, Ospedale di Careggi, Firenze, Italy
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Olona M, Candell-Riera J, Permanyer-Miralda G, Castell J, Barrabés JA, Domingo E, Rosselló J, Vaqué J, Soler-Soler J. Strategies for prognostic assessment of uncomplicated first myocardial infarction: 5-year follow-up study. J Am Coll Cardiol 1995; 25:815-22. [PMID: 7884082 DOI: 10.1016/0735-1097(94)00503-i] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Our aim was to use noninvasive studies early after infarction to assess medium-term prognosis in patients with a first uncomplicated myocardial infarction. BACKGROUND Although the use of early postinfarction assessment to gauge short-term prognosis in myocardial infarction is well established, there have been few comprehensive evaluations of noninvasive methods for assessing medium- and long-term prognosis. METHODS We prospectively studied 115 consecutive patients < 65 years old with a first acute uncomplicated myocardial infarction to evaluate the prognostic role of predischarge cardiac studies. These included submaximal exercise testing, thallium-201 scintigraphy, radionuclide exercise ventriculography, two-dimensional echocardiography, ambulatory electrocardiographic (Holter) monitoring and cardiac catheterization. All patients without complications were followed up > or = 5 years. RESULTS During the follow-up period, 78 patients (68%) developed complications, which were severe in 37 (32%). Exercise thallium-201 scintigraphy yielded the highest percentage (77%) for correctly classified patients. It also had the highest predictive value for complications (97%) and severe complications (92%) when it was used in association with exercise testing and radionuclide ventriculography. The addition of cardiac catheterization did not improve on the predictive power of noninvasive studies. Four decision trees (exercise testing + echocardiography, exercise testing + radionuclide ventriculography, thallium-201 + echocardiography, thallium-201 + radionuclide ventriculography) allowed stratification of all patients in a high, intermediate or low risk category. The combination of thallium-201 scintigraphy and radionuclide ventriculography yielded the best results (90% predictive value for complications if the outcome of both tests was positive), but there were no significant differences with the other models. CONCLUSIONS Any combination of a test detecting residual ischemia or functional capacity, or both (exercise testing or thallium-201 scintigraphy), and a test assessing ventricular function (echocardiography or radionuclide ventriculography) results in useful prognostic information in patients with an uncomplicated first acute myocardial infarction.
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Affiliation(s)
- M Olona
- Servei de Cardiologia, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
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Affiliation(s)
- G S Reeder
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905
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Reperfusion in acute myocardial infarction. International Society and Federation of Cardiology and World Health Organization Task Force on Myocardial Reperfusion. Circulation 1994; 90:2091-102. [PMID: 7923697 DOI: 10.1161/01.cir.90.4.2091] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Zhu WX, Gibbons RJ, Bailey KR, Gersh BJ. Predischarge exercise radionuclide angiography in predicting multivessel coronary artery disease and subsequent cardiac events after thrombolytic therapy for acute myocardial infarction. Am J Cardiol 1994; 74:554-9. [PMID: 8074037 DOI: 10.1016/0002-9149(94)90743-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The value of exercise testing in postinfarction patients receiving thrombolytic therapy has not been established. Ninety-four patients treated acutely with thrombolytic therapy without angioplasty who underwent exercise radionuclide angiography and coronary angiography before hospital discharge were studied. Thirty patients underwent early revascularization, often for multivessel disease. During a median follow-up period of 3.5 years, only 5 patients had "hard" events (cardiac death, cardiac arrest, or myocardial infarction) and 5 other patients underwent late (> 90 days) revascularization. The results of radionuclide angiography did not predict multivessel disease. Peak exercise ejection fraction was the only significant (p = 0.003) independent predictor of events. Among the 65 patients with a peak exercise ejection fraction > or = 40%, the 3-year hard and "combined" event-free survival were 98% and 91%, respectively. Among the 29 patients with a peak exercise ejection fraction < 40%, the 3-year hard and combined event-free survival were 74% and 69%, respectively. Postinfarction patients treated with thrombolytic therapy, who often underwent early revascularization, had an excellent prognosis through 3.5 years of follow-up. Although exercise radionuclide angiography had little value for identifying multivessel disease, a reduced peak exercise ejection fraction was associated with subsequent events.
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Affiliation(s)
- W X Zhu
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905
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van Daele ME, McNeill AJ, Fioretti PM, Salustri A, Pozzoli MM, el-Said ES, Reijs AE, McFalls EO, Slagboom T, Roelandt JR. Prognostic value of dipyridamole sestamibi single-photon emission computed tomography and dipyridamole stress echocardiography for new cardiac events after an uncomplicated myocardial infarction. J Am Soc Echocardiogr 1994; 7:370-80. [PMID: 7917345 DOI: 10.1016/s0894-7317(14)80195-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A high-dose dipyridamole stress test (0.84 mg/kg in 6 minutes) with simultaneous sestamibi single-photon emission computed tomographic (SPECT) and echocardiographic imaging was performed in 89 patients before hospital discharge after an uncomplicated myocardial infarction. The aim of this study was to determine the prognostic value of these tests for new cardiac events and to compare the relative values of SPECT and echocardiography in a postinfarction dipyridamole stress test. Two years after infarction, nine patients (10%) had died, five patients (6%) had suffered a nonfatal reinfarction, and 14 patients (16%) had been readmitted to the hospital for a revascularization procedure. Cardiac death had occurred in 5 (10%) of 48 patients with a positive SPECT versus 4 (10%) of 41 with a negative SPECT (difference not significant) and in 6 (19%) of 31 with a positive echocardiogram versus 3 (5%) of 56 with a negative echocardiogram (p = 0.05). Cardiac death or reinfarction had occurred in 8 (17%) of 48 patients with a positive SPECT versus 6 (15%) of 41 with a negative SPECT (difference not significant) and in 6 (19%) of 31 with a positive echocardiogram versus 8 (14%) of 56 with a negative echocardiogram (difference not significant). Thus the predictive value of the dipyridamole stress test for new cardiac events after an uncomplicated myocardial infarction was limited, irrespective of the method used to detect ischemia. Reversible perfusion defects were identified more frequently than new wall motion abnormalities but did not predict late events. A positive dipyridamole echocardiogram was associated with a higher late mortality rate but did not predict other cardiac events.
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Affiliation(s)
- M E van Daele
- Division of Cardiology, University Hospital Rotterdam-Dijkzigt, The Netherlands
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Simari RD, Berger PB, Bell MR, Gibbons RJ, Holmes DR. Coronary angioplasty in acute myocardial infarction: primary, immediate adjunctive, rescue, or deferred adjunctive approach? Mayo Clin Proc 1994; 69:346-58. [PMID: 8170179 DOI: 10.1016/s0025-6196(12)62220-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To address the current clinical applications, outcomes, and limitations of coronary angioplasty in the setting of acute myocardial infarction. DESIGN We review the results of several large trials in which various strategies of thrombolysis and primary, immediate adjunctive, rescue, or deferred adjunctive coronary angioplasty were used in patients with acute myocardial infarction. MATERIAL AND METHODS Four strategies for the utilization of angioplasty in myocardial infarction have been developed and are based on the timing and concurrent use of thrombolytic therapy. RESULTS Primary coronary angioplasty without prior thrombolytic therapy is as effective as thrombolytic therapy for salvaging myocardium. Results of a meta-analysis of recent trials suggest potential benefits of increased survival and decreased reinfarction in comparison with the results of thrombolysis in recent trials. Immediate adjunctive angioplasty after thrombolytic therapy has been tested in three large, randomized trials. The results suggest that this strategy is associated with increased risks without benefits of increased survival or improved left ventricular function. Rescue angioplasty may be helpful after failed thrombolytic therapy. Ongoing randomized trials might further clarify the benefits of rescue angioplasty. Because of the inherent difficulty in the noninvasive identification of patients with persistent reocclusion, diagnostic coronary angiography early after thrombolytic therapy may be necessary. Deferred adjunctive angioplasty during the weeks after infarction to prevent recurrent ischemia was not shown to decrease mortality or reinfarction in two large trials. CONCLUSION Primary coronary angioplasty is the treatment of choice for patients with contraindications to thrombolytic therapy. Certain high-risk subgroups may also benefit from primary angioplasty.
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Affiliation(s)
- R D Simari
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic Rochester, Minnesota 55905
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Gimple LW, Beller GA. Assessing prognosis after acute myocardial infarction in the thrombolytic era. J Nucl Cardiol 1994; 1:198-209. [PMID: 9420687 DOI: 10.1007/bf02984092] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The use of physiologic testing for prognostication continues to be useful and widely applied in the predischarge evaluation of patients recovering from an uncomplicated acute myocardial infarction in the thrombolytic era. Because patients with abnormal exercise test results are now routinely sent for angiography, there are no randomized trials or experimental confirmation that exercise parameters are still associated with the same prognostic value in the thrombolytic era. Nevertheless, the excellent outcomes in patients treated with thrombolytic therapy and risk stratified with exercise testing provide strong empiric support for the continued use of noninvasive testing of patients without complications after thrombolytic therapy. Reviews of patient cohorts enrolled in trials of thrombolytic therapy show that these patients have a lower incidence of multivessel disease and less evidence of ischemia (ST segment depression or thallium 201 redistribution) compared with prethrombolytic cohorts. For this and other reasons, the sensitivity and specificity of exercise variables for prognosis or detection of multivessel disease are not as strong. The addition of perfusion imaging will enhance the sensitivity for detection of ischemia within or remote from the infarct zone and will provide information regarding viability. Patients who are unable to exercise or those with poor exercise tolerance, an abnormal exercise blood pressure response, inducible ischemia, or nonsustained ventricular tachycardia are candidates for further invasive evaluation and consideration for coronary revascularization. With 201Tl imaging, evidence for increased pulmonary uptake of the tracer is indicative of high risk and a high probability of an adverse outcome with medical therapy. Low-risk patients are those who achieve their target heart rate or work load without inducible angina, ST segment depression, reversible perfusion abnormalities, or increased lung 201Tl uptake. Defect size is reflective of infarct size, and patients with extensive areas of nonreversible hypoperfusion are also at high risk for future events even in the absence of ischemia. Finally, pharmacologic stress imaging with dipyridamole, adenosine, or dobutamine has been found to be safe when employed for stress testing soon after uncomplicated infarction.
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Affiliation(s)
- L W Gimple
- Department of Medicine, Cardiovascular Division, University of Virginia Health Sciences Center, Charlottesville, USA
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Chesebro JH, Badimon JJ, Ortiz AF, Meyer BJ, Fuster V. Conjunctive antithrombotic therapy for thrombolysis in myocardial infarction. Am J Cardiol 1993; 72:66G-74G. [PMID: 8279364 DOI: 10.1016/0002-9149(93)90110-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Disruption of an atherosclerotic plaque in coronary arteries with a minor stenosis is the usual stimulus for acute coronary thrombosis and myocardial infarction. In this article the pathogenesis of arterial thrombosis and contributions of local arterial wall substrates, the rheology of blood flow, systemic factors, and the critical role of thrombin in the formation of thrombus are discussed. More potent antithrombotic therapy may accelerate exogenous thrombolysis, allows endogenous thrombolysis, and should reduce recurrent infarction and ischemia and death, as well as need for coronary revascularization. Maximal antithrombotic therapy for acute myocardial infarction includes an intravenous bolus of heparin at 100 U/kg followed by an intravenous infusion--at 1,200 U/hr for patients weighing 60-80 kg, 1,300 U/hr for those weighing > 80 kg, and 1,000 U/hr for those weighing < 60 kg (or 17 U/kg/hr)--to maintain the activated partial thromboplastin time at 2-3 times control (60-90 sec) for at least 5-7 days. To convert intravenous to subcutaneous administration, use 14,000-17,000 U every 12 hours and initially overlap the intravenous infusion by 2 hours. The loading dose of aspirin on admission to the hospital is 160 mg followed by 80 mg/day. High-risk patients should be considered for conversion of heparin to warfarin therapy for at least 3 months at an international normalized ratio of 2.5-4.0 for the prevention of recurrent ischemia, reinfarction, death, thromboembolism, reactivation of thrombosis, and reduced necessity for revascularization.
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Affiliation(s)
- J H Chesebro
- Cardiac Unit, Massachusetts General Hospital, Boston 02114
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Haber HL, Beller GA, Watson DD, Gimple LW. Exercise thallium-201 scintigraphy after thrombolytic therapy with or without angioplasty for acute myocardial infarction. Am J Cardiol 1993; 71:1257-61. [PMID: 8498363 DOI: 10.1016/0002-9149(93)90536-l] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Scant data are available concerning the application and results of exercise thallium-201 (Tl-201) scintigraphy after acute myocardial infarction (AMI) treated with thrombolytic therapy. The goals of this study were to determine the ability of exercise Tl-201 scintigraphy to detect inducible ischemia and to identify multivessel coronary artery disease (CAD) in 88 consecutive postinfarction patients who received thrombolytic therapy and underwent both predischarge noninvasive testing and coronary angiography. Exercise-induced Tl-201 redistribution on quantitative scintigraphy was significantly more prevalent than exercise ST-segment depression (48 vs 14%, p < 0.001). Sensitivity and specificity of exercise ST depression alone for identification of multivessel disease was 29 and 96%, respectively. Sensitivity of a remote Tl-201 defect for multivessel CAD detection was 35 and 87%, respectively--not significantly different from values for ST depression alone. When considered as a single variable, the presence of either ST depression or a remote Tl-201 defect was associated with a 58% sensitivity (p < 0.05, compared with either ST depression or Tl-201 redistribution alone), but a somewhat diminished specificity of 78%. There was no difference in extent or severity of angiographic CAD in patients with multivessel CAD with or without inducible ischemia. In conclusion, this study shows that exercise Tl-201 imaging is more sensitive than exercise Tl-201 imaging is more sensitive than exercise ST depression for detection of residual ischemia during submaximal exercise in patients who received thrombolytic therapy for AMI. The combination of the presence of either Tl-201 redistribution or ischemic ST depression was better than either variable alone for identifying patients with multivessel CAD.
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Affiliation(s)
- H L Haber
- Department of Internal Medicine, University of Virginia Health Sciences, Center, Charlottesville 22908
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Chaitman BR, McMahon RP, Terrin M, Younis LT, Shaw LJ, Weiner DA, Frederick MM, Knatterud GL, Sopko G, Braunwald E. Impact of treatment strategy on predischarge exercise test in the Thrombolysis in Myocardial Infarction (TIMI) II Trial. Am J Cardiol 1993; 71:131-8. [PMID: 8421972 DOI: 10.1016/0002-9149(93)90727-t] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Predischarge supine bicycle ergometry was used to assess persistent myocardial ischemia in postinfarction patients who received thrombolytic therapy and were randomized to an invasive versus conservative strategy in the Thrombolysis in Myocardial Infarction (TIMI) II trial. The frequency of ischemic responses in both strategies, and the 1-year prognostic importance of the different exercise test outcomes were examined. At 14 days, the percentage of patients with any adverse outcome (including death, presence of exercise-induced ST-segment depression, or inability to perform the exercise test) was 33.7% of 1,681 randomly assigned to the invasive strategy compared with 34.6% of 1,658 randomly assigned to the conservative strategy (p = 0.57). The 1-year mortality was greater in patients who did not perform the predischarge exercise test (7.7%) than in those who did (1.8%) (p < 0.001); the former were older, and a greater proportion were women, had a more frequent history of myocardial infarction, and more extensive coronary artery disease (p < 0.01 for each comparison). The 1-year mortality in patients with exercise-induced ST-segment depression or chest pain was only 1.4% (3 of 22) among those randomly assigned to the conservative strategy where coronary angiography and revascularization were recommended if the test result was abnormal (relative risk compared with those without ST-segment depression or chest pain 0.6; 99% confidence interval 0.1 to 2.9).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- B R Chaitman
- TIMI Coordinating Center, Maryland Medical Research Institute, Inc., Baltimore 21210
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Vacek JL, Rosamond TL, Kramer PH, Crouse LJ, Robuck OW, White JL, Beauchamp GD. Direct angioplasty versus initial thrombolytic therapy for acute myocardial infarction: long-term follow-up and changes in practice pattern. Am Heart J 1992; 124:1411-8. [PMID: 1462893 DOI: 10.1016/0002-8703(92)90051-v] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We retrospectively studied the outcomes of patients with acute myocardial infarction who were treated with either direct angioplasty or thrombolytics followed by angioplasty. Two patient cohorts were analyzed: a previously reported (in regard to short-term follow-up) group of 371 patients who now have long-term follow-up (mean, 3.4 years) of survival and event-free survival and a second group of 202 patients who have been treated since publication of our initial data. Both 1-year and 2-year survival were significantly better (p = 0.01 and 0.02, respectively) in the group that was treated with thrombolytics first. Event-free survival (i.e., no myocardial infarction, coronary artery bypass graft surgery, repeat angioplasty) was better overall (p < 0.01) for the group that was treated with thrombolytics first. The more recently treated group of patients also showed benefit in regard to both survival (p = 0.002) and event-free survival (p < 0.01) over a short-term follow-up period (mean, 39 weeks) for patients who were treated initially with thrombolytics as compared with those who were treated with direct angioplasty. Although the initial cohort was very similar to the treatment groups except for age (mean age for the direct angioplasty group was 62 +/- 12 years vs 57 +/- 11 years for thrombolytics first group, (p = 0.0002), several differences existed in the more recent treatment groups. The patients who were more recently treated with direct angioplasty were older, had lower mean ejection fraction, had more extensive coronary artery disease, and were more likely to have had prior coronary artery bypass grafting.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J L Vacek
- Mid-America Heart Institute, St. Luke's Hospital, Kansas City, Missouri
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Abstract
Following successful pharmacologic thrombolysis, early coronary angiography frequently shows a tight residual stenosis in the infarct-related artery at the site of recent occlusion. Approaches to the management of the residual stenosis have undergone a gradual evolution from an aggressive strategy of immediate balloon dilation to a more conservative approach. Randomized, controlled trials have indicated that immediate percutaneous transluminal coronary angioplasty (PTCA) is associated with no greater recovery in regional or global left ventricular function, and a tendency toward an increased incidence of complications, including the need for emergency coronary artery surgery and blood transfusion. The role of immediate rescue PTCA for failed thrombolysis has not been as rigorously investigated, but selected patients, including those with evidence of ongoing myocardial ischemia or hemodynamic instability, may benefit from this approach. A major source of current controversy is the value of routine coronary angiography after uncomplicated myocardial infarction. Two carefully conducted trials have indicated that a conservative strategy of clinically indicated, predischarge cardiac catheterization may be associated with an increased need for readmission and late, elective cardiac catheterization when compared with a more invasive strategy of routine coronary angiography, but that the conservative approach is not associated with an increased incidence of death or reinfarction. Provision was not made in these studies, however, for evaluating the positive economic and psychologic impact of early coronary angiography, early hospital discharge, and early return to work of patients with a favorable postinfarction prognosis. It is concluded that early mechanical revascularization following thrombolysis should be considered for ongoing myocardial ischemia, but should otherwise be deferred pending the results of predischarge functional studies. For most patients, routine coronary angiography is likely to remain an important diagnostic tool and an integral component of the management of the convalescent phase of acute myocardial infarction.
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Affiliation(s)
- D W Muller
- Division of Cardiology, University of Michigan Medical Center, Ann Arbor 48109-0022
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