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Mishra A, Prajapati J, Dubey G, Patel I, Mahla M, Bishnoi S, Pandey V. Characteristics of ST-elevation myocardial infarction with failed thrombolysis. Asian Cardiovasc Thorac Ann 2020; 28:266-272. [PMID: 32493040 DOI: 10.1177/0218492320932074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Fibrinolytic therapy is an important reperfusion strategy, especially when primary percutaneous coronary interventions cannot be offered to ST-elevation myocardial infarction patients. Given that failed reperfusion after fibrinolytic therapy is common, it is pragmatic that the predictors, outcomes, and angiographic profiles of patients with failed thrombolysis are carefully scrutinized. METHODS We prospectively studied clinical variables and outcomes over 30 months in 243 ST-elevation myocardial infarction patients who received fibrinolytics as primary treatment. Logistic regression analysis was used to identify predictors of failed thrombolysis. RESULTS Failed thrombolysis occurred in 38.68% of patients with a mean window period of 6.58 ± 1.42 h, and 55.32% of patients with failed thrombolysis had Killip class >I on presentation. Risk factors such as diabetes mellitus (55.32%), dyslipidemia (60.64%) and obesity (77.66%) were frequently associated with failed thrombolysis; 73.40% of patients with failed thrombolysis had Thrombolysis in Myocardial Infarction flow grade 0/1 in the infarct-related artery, and 58.51% of such patients needed a rescue percutaneous coronary intervention. The mean Thrombolysis in Myocardial Infarction risk score was 5.46 ± 2.77 in failed thrombolysis patients, with mortality of 4.25% at the 6-month follow-up. CONCLUSION Non-resolution of presenting symptoms and ST changes on electrocardiography at 90 min served as the earliest indicators of failed thrombolysis, with a significant angiographic correlation. Clinical variables such as delayed presentation (>6 h), dyspnea, Killip class >I, cardiogenic shock, Thrombolysis in Myocardial Infarction score, and conventional risk factors including diabetes mellitus, dyslipidemia, and obesity represented cluster of predictors of failed thrombolysis.
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Affiliation(s)
- Ashish Mishra
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Jayesh Prajapati
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Gajendra Dubey
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Iva Patel
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Mukesh Mahla
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Suresh Bishnoi
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Vimlesh Pandey
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
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Bertrand OF, Larose É, Bagur R, Maes F, Gaudreault V, Noël B, Barbeau G, Déry JP, Pirlet C, Costerousse O. A Randomized Double-Blind Placebo-Controlled Study Comparing Intracoronary Versus Intravenous Abciximab in Patients With ST-Elevation Myocardial Infarction Undergoing Transradial Rescue Percutaneous Coronary Intervention After Failed Thrombolysis. Am J Cardiol 2018; 122:47-53. [PMID: 29699748 DOI: 10.1016/j.amjcard.2018.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/12/2018] [Accepted: 03/16/2018] [Indexed: 11/18/2022]
Abstract
The risk and benefit ratio of glycoprotein IIb/IIIa inhibitors with dual oral antiplatelet therapy after failed thrombolysis and rescue percutaneous coronary intervention (PCI) is unclear. Using a randomized placebo-controlled, double-blind design, we compared intravenous (IV) and intracoronary (IC) abciximab delivery in 74 patients referred for rescue transradial PCI. The primary angiographic end points were the final thrombolysis in myocardial infarction flow and myocardial blush grades. Secondary end points included acute and 6-month outcomes using angiographic parameters, platelet aggregation parameters, cardiac biomarkers, cardiac magnetic resonance measurements (CMR) and clinical end points. After rescue PCI, normal thrombolysis in myocardial infarction 3 flows were obtained in 70% in the IC group, 48% in the IV group, and 71% in the placebo group, respectively (p = 0.056). Final myocardial blush grades 2 and 3 were obtained in 43% and 39% in the IC group, 48% and 26% in the IV group, and 46% and 42% in the placebo group (p = 0.67), respectively. Acutely, peak release of cardiac biomarkers, necrosis size, myocardial perfusion and no-reflow as assessed by CMR, and clinical end points were similar between the groups and did not suggest a benefit for IC or IV abciximab compared with placebo. There was no increase in bleeding or access site-related complications with abciximab compared with placebo. Clinical, angiographic, and CMR outcomes at 6 months remained comparable between the groups. In patients with ST-elevation myocardial infarction presenting with failed thrombolysis undergoing transradial rescue PCI, IC or IV abciximab had no significant clinical impact.
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Jain J, Narang U, Gupta OP, Kalantri SP, Joshi S, Bhadoriya S. Utility of ST score on admission as a marker for outcome in acute myocardial infarction in a resource constrained setting. JOURNAL OF MAHATMA GANDHI INSTITUTE OF MEDICAL SCIENCES 2018. [DOI: 10.4103/jmgims.jmgims_27_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chang RY, Tsai HL, Hsiao PG, Tan CW, Lee CP, Chu IT, Chen YP, Chen CY. Comparison of the risk of left ventricular free wall rupture in Taiwanese patients with ST-elevation acute myocardial infarction undergoing different reperfusion strategies: A medical record review study. Medicine (Baltimore) 2016; 95:e5308. [PMID: 27858909 PMCID: PMC5591157 DOI: 10.1097/md.0000000000005308] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Ventricular free wall rupture (VFWR) is the second most common cause of death in patients with acute ST-elevation myocardial infarction (STEMI). Nevertheless, few reports have investigated the factors, including different treatment strategies, associated with VFWR in Taiwanese patients. Therefore, the aim of this study was to compare the risk of VFWR in Taiwanese patients with acute STEMI who had received primary percutaneous coronary intervention (PCI), rescue PCI, scheduled PCI, thrombolytic therapy, and pharmacologic treatment. In this medical records review study, records of patients with acute STEMI admitted to a regional hospital in south Taiwan between March 1999 and October 2013 were screened. Multivariate stepwise logistic regression analysis was used to evaluate the association between the risk of VFWR and its independent factors. The overall incidence of VFWR among the 1545 patients with acute STEMI in this study was 1.6%. Compared with primary PCI, the risk of VFWR was significantly higher in patients who had received thrombolysis (adjusted odds ratio = 6.83, P = 0.003) or pharmacologic treatment alone (adjusted odds ratio = 3.68, P = 0.014). The risk of VFWR in patients receiving rescue PCI or scheduled PCI was not significantly different from that in patients receiving primary PCI. In addition, older age and Killip class >I were associated with an increased risk of VFWR in patients with acute STEMI, whereas the use of angiotensin-converting enzyme inhibitors was associated with a lower risk of VFWR. In conclusion, findings from this medical record review study provide support for the use of primary PCI, rescue PCI, and scheduled PCI over thrombolytic therapy and pharmacologic treatment in reducing the risk of VFWR in Taiwanese patients with acute STEMI.
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Affiliation(s)
- Rei-Yeuh Chang
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital
- Department of Nursing, Chung Jen Junior College of Nursing, Health Sciences and Management, Chiayi
- Department of Beauty and Health Care, Min-Hwei Junior College of Health Care Management, Tainan City, Taiwan
- Correspondence: Rei-Yeuh Chang, Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City 60002, Taiwan (e-mail: )
| | - Han-Lin Tsai
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital
| | - Ping-Gune Hsiao
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital
| | - Chao-Wen Tan
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital
| | - Chi-Pin Lee
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital
| | - I-Tseng Chu
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital
| | - Yung-Ping Chen
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital
| | - Cheng-Yun Chen
- Division of Cardiology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital
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Tadros GM, Islam MA, Mirza A, Blankenship JC, Iliadis EA. Angiographic and Long-Term Outcomes of “Rescue” Stenting versus PTCA in Failed Thrombolysis in Acute Myocardial Infarction. Angiology 2016; 55:169-76. [PMID: 15026872 DOI: 10.1177/000331970405500209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Percutaneous transluminal coronary angioplasty (PTCA), when performed early after clinically failed thrombolysis, improves acute infarct-artery patency in up to 90% of cases. Limited data are available regarding the role of rescue stenting in this setting. From January 1995 to December 1999, the authors studied all consecutive patients treated with rescue PTCA or rescue stenting within 12 hours of onset of chest pain and clinically failed thrombolytic therapy at their institution. Baseline demographic characteristics, infarct-related artery location, lesion class, left ventricular function, and incidence of multivessel disease were similar between groups (23 patients in each group). Preprocedural TIMI flow 0 was more common in PTCA patients (p=0.025). Quantitative coronary analysis revealed similar incidence of calcification, thrombus burden, minimal lumen diameter (MLD), and lesion length between groups. Post-procedural TIMI 3 flow was more common in stent patients; however, this was not statistically significant (p=0.18). Greater final MLD (p<0.001), less residual stenosis (p<0.001), and a trend toward larger reference vessel diameter (p=0.13) were observed in favor of stent patients. At 6-month follow-up, there was no difference in the incidence of death, myocardial infarction, or readmission for unstable angina between groups. More stent patients (60% vs 27%, p=0.06) were angina free as compared to PTCA patients. Despite similar in-hospital clinical outcomes, the study suggests better angiographic results and 6-month morbidity with rescue stenting.
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Affiliation(s)
- George M Tadros
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA.
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6
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Lim SY. No-Reflow Phoenomenon by Intracoronary Thrombus in Acute Myocardial Infarction. Chonnam Med J 2016; 52:38-44. [PMID: 26865998 PMCID: PMC4742608 DOI: 10.4068/cmj.2016.52.1.38] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/29/2015] [Accepted: 01/03/2016] [Indexed: 12/28/2022] Open
Abstract
Recently, percutaneous coronary intervention has been the treatment of choice in most acute myocardial infarction cases. Although the results of percutaneous coronary interventions have ben good, the no-reflow phenomenon and distal embolization of intracoronary thrombus are still major problems even after successful interventions. In this article, we will briefly review the deleterious effects of no-reflow and distal embolization of intracoronary thrombus during percutaneous coronary interventions. The current trials focused on the prevention and treatment of the no-reflow phenomenon and intracoronary thrombus.
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Affiliation(s)
- Sang Yup Lim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
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7
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Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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8
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Burjonroppa SC, Varosy PD, Rao SV, Ou FS, Roe M, Peterson E, Singh M, Shunk KA. Survival of Patients Undergoing Rescue Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2011; 4:42-50. [DOI: 10.1016/j.jcin.2010.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 08/02/2010] [Accepted: 09/17/2010] [Indexed: 10/18/2022]
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9
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Carver A, Rafelt S, Gershlick AH, Fairbrother KL, Hughes S, Wilcox R. Longer-Term Follow-Up of Patients Recruited to the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) Trial. J Am Coll Cardiol 2009; 54:118-26. [DOI: 10.1016/j.jacc.2009.03.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 03/23/2009] [Accepted: 03/24/2009] [Indexed: 10/20/2022]
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10
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Hermanides R, Ottervanger JP. Treatment of ST-elevation myocardial infarction. Future Cardiol 2008; 4:391-7. [PMID: 19804319 DOI: 10.2217/14796678.4.4.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In patients with ST-segment elevation myocardial infarction (STEMI), timely and adequate treatment may improve the prognosis dramatically. Restoration of the infarct vessel patency is one of the cornerstones of initial treatment. Compared with fibrinolytic therapy, primary percutaneous coronary intervention (PCI) results in improved short- and long-term survival, a lower incidence of recurrent infarction and a better left ventricular function. Although (drug-eluting) stents may reduce restenosis, effects on mortality are less clear. Administration of glycoprotein IIb/IIIa antagonists may further reduce periprocedural coronary complications, but bivalirudin may offer similar effects with less bleeding. beta-adrenergic blockers, angiotensin-converting-enzyme inhibitors and statins should be initiated in all patients with STEMI, although cautious use of beta-blockers is advised in patients at risk of cardiac shock. Patients with diabetes should receive optimal glucose control. High-risk patients, particularly those with a low ejection fraction, should receive an implantable cardioverter defibrillator after 30 days, although it is not clear whether patients who have received primary PCI also benefit, particularly if they have no signs of heart failure.
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Affiliation(s)
- Rik Hermanides
- Isala klinieken, Department of Cardiology, Groot Wezenland 20, 8011 JW Zwolle, The Netherlands
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11
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Dangas G, Stone GW, Weinberg MD, Webb J, Cox DA, Brodie BR, Krucoff MW, Gibbons RJ, Lansky AJ, Mehran R. Contemporary outcomes of rescue percutaneous coronary intervention for acute myocardial infarction: comparison with primary angioplasty and the role of distal protection devices (EMERALD trial). Am Heart J 2008; 155:1090-6. [PMID: 18513524 DOI: 10.1016/j.ahj.2007.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Accepted: 12/05/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND The value of distal protection devices during rescue PCI has not been studied. METHODS The population enrolled in a prospective, randomized multicenter trial of distal microcirculatory protection in ST-elevation MI, was stratified for those undergoing rescue (n = 93) or primary (n = 408) PCI; we performed the prespecified comparisons of distal protection in rescue and primary PCI. RESULTS Compared to primary PCI, rescue patients had higher baseline rates of TIMI-3 flow, but lower rates of post PCI TIMI-3 flow. However, no differences in the primary endpoints of complete ST-segment resolution (STR) at 30 minutes or infarct size, or 6 month mortality were present. In rescue PCI patients, randomization to distal protection did not significantly affect infarct size, STR, mortality or other clinical events. CONCLUSION Despite reduced rates of post-procedural TIMI-3 flow, patients undergoing rescue PCI compared to primary PCI have similar myocardial perfusion, infarct size and clinical outcomes. Distal protection did not offer any detectable benefit in this patient population.
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12
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Relation of hyperemic epicardial flow to outcomes among patients with ST-segment elevation myocardial infarction receiving fibrinolytic therapy. Am J Cardiol 2008; 101:1232-8. [PMID: 18435949 DOI: 10.1016/j.amjcard.2007.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Revised: 12/27/2007] [Accepted: 12/27/2007] [Indexed: 11/21/2022]
Abstract
In patients with ST-segment elevation myocardial infarction (STEMI), the restoration of normal epicardial flow following fibrinolytic administration is associated with improved clinical outcomes. The goal of this analysis was to examine the relation between hyperemic flow and outcomes following fibrinolytic administration for STEMI. In Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis In Myocardial Infarction 28 (CLARITY-TIMI 28), patients with STEMI (n=3,491) treated with fibrinolytic therapy were scheduled to undergo angiography 48 to 192 hours after randomization. Corrected TIMI frame count (CTFC) and TIMI myocardial perfusion grade (TMPG) were assessed, and their associations with outcomes at 30 days were evaluated. When evaluating initial angiography of the infarct-related artery, there was a nearly linear relation between CTFC and 30-day mortality, with faster flow (lower CTFC) associated with improved outcomes. Conversely, in patients who underwent percutaneous coronary intervention (PCI), very fast flow (CTFC<14) after intervention was associated with worse outcomes. Post-PCI hyperemic flow (CTFC<14) was associated with a higher incidence of mortality (p=0.056), recurrent myocardial infarction (p=0.011), and a composite of death or myocardial infarction (p<0.001) compared with normal flow (CTFC 14 to 28). When post-PCI CTFC was further stratified by TMPG, there was a U-shaped relation between mortality and CTFC in patients with poor myocardial perfusion (TMPG 0 or 1). This relation appeared to be linear in patients with TMPG 2 or 3. In conclusion, in patients who undergo PCI after fibrinolytic therapy for STEMI, hyperemic flow on coronary angiography is associated with an increased incidence of adverse outcomes. Hyperemic flow with associated impaired myocardial perfusion may be a marker of more extensive downstream microembolization.
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Kunadian B, Vijayalakshmi K, Dunning J, Sutton AGC, Muir DF, Wright RA, Hall JA, de Belder MA. Rescue angioplasty after failed fibrinolysis foracute myocardial infarction: Predictors of a failed procedure and 1-year mortality. Catheter Cardiovasc Interv 2008; 71:138-45. [DOI: 10.1002/ccd.21273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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14
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Pride YB, Buros JL, Lord E, Southard MC, Harrigan CJ, Ciaglo LN, Sabatine MS, Cannon CP, Gibson CM. Angiographic perfusion score in patients treated with PCI at late angiography following fibrinolytic administration for ST-segment elevation myocardial infarction is associated with morbidity and mortality at 30 days. J Thromb Thrombolysis 2007; 26:106-12. [PMID: 17624497 DOI: 10.1007/s11239-007-0075-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Accepted: 06/21/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Among patients with ST-segment elevation myocardial infarction (STEMI), evidence of restoration of both normal epicardial arterial flow and myocardial perfusion early after the administration of fibrinolytic agents has been associated with improved clinical outcomes. In STEMI patients treated with fibrinolytic therapy and scheduled for angiography later during hospital admission, however, the association of later indices of flow and perfusion with clinical outcomes has not been assessed. METHODS Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction (CLARITY-TIMI) 28 enrolled 3,491 STEMI patients treated with fibrinolytic therapy. Angiography was scheduled 48-192 h (median 84) after randomization. The Angiographic Perfusion Score (APS) (the sum of the TIMI Flow Grade and Myocardial Perfusion Grade before and after percutaneous coronary intervention (PCI), range of 0-12) was assessed in the 1,460 patients treated with PCI at late angiography, and its association with morbidity and mortality at 30 days was examined. RESULTS Full perfusion, defined as an APS of 10-12, was associated with the lowest mortality (0.8%), while partial perfusion (APS 4-9) (2.3%) and failed perfusion (APS 0-3) (18.0%) were associated with a higher incidence of mortality at 30 days (P < 0.001 for full perfusion vs. partial perfusion, P < 0.0001 for overall trend). In addition, full perfusion was associated with a lower incidence of recurrent myocardial infarction (MI), a composite of death and MI, recurrent myocardial ischemia, ventricular tachyarrhythmia, congestive heart failure and shock (P < 0.05 for all trends). CONCLUSION Among STEMI patients treated with late PCI following fibrinolytic therapy, higher APS is associated with reduced morbidity and mortality.
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Affiliation(s)
- Yuri B Pride
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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15
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Yalonetsky S, Gruberg L, Sandach A, Hammerman H, Beyar R, Hod H, Behar S. Rescue percutaneous coronary intervention after failed thrombolysis: results from the Acute Coronary Syndrome Israel Surveys (ACSIS). ACTA ACUST UNITED AC 2007; 8:83-6. [PMID: 16885071 DOI: 10.1080/17482940600757221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The benefit of rescue percutaneous coronary intervention (PCI) in acute myocardial infarction patients, who fail to show signs of reperfusion after full dose thrombolysis, is still an unresolved issue. AIM To assess the outcomes of patients who underwent rescue PCI after full-dose thrombolytic therapy and compare them to patients treated only with thrombolysis in the Acute Coronary Syndrome Israel Surveys (ACSIS). METHODS ACSIS is a biannual survey on acute myocardial infarction performed in all 26 intensive cardiac care units in Israel during a two-month period. 2,018 patients were admitted with acute myocardial infarction during the two-month period in the 2000 and 2002 surveys, and 796 of them were treated with thrombolytic therapy. RESULTS Rescue PCI was performed in 99 patients who failed to show signs of reperfusion. The control group consisted of patients with unsuccessful thrombolysis and no further intervention. Patients who underwent rescue PCI had a numerically higher incidence of anterior wall myocardial infarction, diabetes, higher Killip class on admission and cardiogenic shock. Furthermore, almost half of these patients had reduced left ventricular function (P = 0.03). During hospitalization, there was a significantly higher prevalence of recurrent ischemic events and major bleeding complications in patients who underwent rescue PCI. In-hospital, 30-day and one-year mortality rates were similar between the two groups. By multivariate analyses, Killip class 3-4 (OR: 2.62, CI = 0.95-6.58, P = 0.05) and streptokinase treatment (OR: 0.623, CI = 0.4-0.97, P = 0.05) were independent predictors of rescue PCI. Rescue angioplasty was associated with 15% risk-reduction (CI = 0.45-1.97, P = 0.05) in 30-day mortality and recurrent emergent hospitalization. CONCLUSIONS Patients who underwent rescue PCI had similar short- and long-term mortality rates compared to patients treated with thrombolysis alone, despite differences in baseline characteristics. Rescue angioplasty was associated with a 15% risk reduction in mortality at 30-days, at the cost of higher rate of recurrent ischemic events and bleeding complications. Therefore, rescue angioplasty may be an equalizer in severely ill patients who receive thrombolytic therapy and fail to show signs of reperfusion.
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Affiliation(s)
- Sergei Yalonetsky
- Division of Invasive Cardiology, Rambam Medical Center, Haifa, Israel
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16
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Wilson JM, Ferguson JJ, Hall RJ. Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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17
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Mendoza CE, Bhatt MR, Virani S, Schob AH, Levine S, Ferreira AC, de Marchena E. Management of failed thrombolysis after acute myocardial infarction: An overview of current treatment options. Int J Cardiol 2007; 114:291-9. [PMID: 17079034 DOI: 10.1016/j.ijcard.2006.07.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Revised: 07/08/2006] [Accepted: 07/17/2006] [Indexed: 11/16/2022]
Abstract
Thrombolytic therapy remains the most commonly administered revascularization strategy for patients with ST-elevation myocardial infarctions (STEMI). However, many patients fail to have patent arteries or ST-segment resolution after these therapies. Multiple strategies have been examined to treat these patients with "failed thrombolysis." We examined the existing medical literature regarding treatment of failed thrombolysis including strategies testing repeat thrombolytic therapy and rescue percutaneous coronary intervention. Additional, we reviewed the literature regarding the efficacy of transferring patient for rescue percutaneous intervention and coronary stenting. The impact of contemporary antiplatelet strategies, cardiogenic shock, and coronary bypass surgery was examined. Overall, the management of patients with acute STEMI in whom thrombolytic therapy failed remains a challenging problem. As a result, many different strategies are currently in use. Among these therapeutic interventions, rescue PCI with coronary stenting appears to be superior when it is done in a timely manner by an experienced center.
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18
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Patel TN, Bavry AA, Kumbhani DJ, Ellis SG. A meta-analysis of randomized trials of rescue percutaneous coronary intervention after failed fibrinolysis. Am J Cardiol 2006; 97:1685-90. [PMID: 16765114 DOI: 10.1016/j.amjcard.2006.01.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Revised: 01/04/2006] [Accepted: 01/04/2006] [Indexed: 11/29/2022]
Abstract
Previous trials have suggested clinical benefit with rescue percutaneous coronary intervention (PCI) after failed fibrinolysis, but more recent, larger studies are conflicting. Therefore, we designed a meta-analysis to determine whether rescue PCI improves outcomes compared with conservative therapy in the setting of early failure of fibrinolysis. We searched MEDLINE for randomized trials by using the Medical Subject Heading terms "angioplasty," "myocardial infarction," "thrombolytic therapy," and "fibrinolysis." The inclusion criteria were (1) acute ST-elevation myocardial infarction initially treated with fibrinolytics, (2) randomization of patients with failed fibrinolysis to immediate PCI or conservative therapy, and (3) available short-term clinical outcome data. The primary end point was short-term mortality and secondary end points were thromboembolic stroke and heart failure. Numbers of events were tabulated for each trial and risk ratios (RRs) were computed. Five trials were included for analysis. The pooled RR estimates showed a 36% decrease in the risk of death in the rescue arm (RR 0.64, 95% confidence interval 0.41 to 1.00, p=0.048) and a marginally significant 28% decrease in the risk of heart failure (RR 0.72, 95% confidence interval 0.51 to 1.01, p=0.06). We also found a marginally increased risk of thromboembolic stroke in the rescue arm (RR 3.61, 95% confidence interval 0.91 to 14.27, p=0.07). In conclusion, rescue PCI in the setting of early fibrinolytic failure improves mortality, but this is tempered by a possible increase in the risk of thromboembolic stroke.
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Affiliation(s)
- Taral N Patel
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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19
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Holmes DR, Gersh BJ, Ellis SG. Rescue percutaneous coronary intervention after failed fibrinolytic therapy: have expectations been met? Am Heart J 2006; 151:779-85. [PMID: 16569532 DOI: 10.1016/j.ahj.2005.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 12/06/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Reperfusion therapy for acute myocardial infarction has revolutionized modern cardiovascular care. METHODS AND RESULTS Two strategies have been tested widely: fibrinolytic therapy and percutaneous coronary intervention (PCI). Fibrinolytic therapy has the advantage that it can be given in many medical care institutions that do not have immediate access to catheterization laboratories. Unfortunately, in a substantial number of patients, fibrinolytic therapy may not achieve optimal results, and a strategy of rescue or salvage PCI may be undertaken. There is a relative paucity of evidence-based outcomes on which to judge the merits of rescue PCI, although the volume is increasing. CONCLUSIONS At present, several recommendations can be offered: (1) implementation of a policy of rescue PCI requires clear guidelines of patient selection, training of personnel, logistics of patient movement, and outcomes assessment; and (2) there needs to be heightened awareness with a high index of suspicion about the potential failure of fibrinolytic therapy.
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Affiliation(s)
- David R Holmes
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Shavelle DM, Salami A, Abdelkarim M, French WJ, Shook TL, Mayeda GS, Burstein S, Matthews RV. Rescue percutaneous coronary intervention for failed thrombolysis. Catheter Cardiovasc Interv 2006; 67:214-20. [PMID: 16408298 DOI: 10.1002/ccd.20583] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Previous studies of rescue percutaneous coronary intervention (PCI) for failed thrombolysis yielded conflicting results. In the current era of newer thrombolytic agents, coronary stents, glycoprotein IIb/IIIa inhibitors, and aggressive hemodynamic support, the outcome of this high-risk patient group has not been characterized. METHODS From January 2000 to October 2004, 214 consecutive patients were transferred and underwent emergent coronary angiography following failed thrombolysis. One hundred and fifty five (72%) underwent immediate PCI, 23 (11%) underwent delayed PCI, and 36 (17%) received surgical revascularization or medical therapy. Medical records and angiograms for the entire PCI cohort (n=178) were reviewed for in-hospital events including bleeding complications, stroke, recurrent ischemia or myocardial infarction (MI), target vessel revascularization (TVR), and death. RESULTS Time from symptom onset to thrombolysis (mean +/- standard deviation) was 5.6 +/- 11.9 hr, and time from thrombolysis to angiography was 7.0 +/- 5.5 hr. The study cohort was critically ill, with 9.6% experiencing cardiac arrest, 21% in cardiogenic shock, and 12% intubated prior to transfer. Coronary stents were placed in 88%, Rheolytic thrombectomy was used in 21%, an intraaortic balloon pump was placed in 17%, and a glycoprotein IIb/IIIa inhibitor was administered in 92%. Patients receiving delayed PCI had higher TIMI 3 flow grade at initial angiography than those receiving immediate PCI (83% vs. 34%, respectively, P < 0.0001). Angiographic success was 90% for the entire PCI cohort, 89% for the immediate PCI group, and 100% for the delayed PCI group. Clinical success (angiographic success and freedom from major adverse cardiac events) was 85% for the entire PCI cohort, 83% for the immediate PCI group, and 100% for the delayed PCI group. Severe and moderate bleeding complications occurred in 7.3%, stroke in 1.7%, recurrent ischemia or MI in 7.3%, and TVR in 3.4%. Overall, in-hospital mortality for the entire PCI cohort was 3.4%. CONCLUSIONS This observational, consecutive, real-world study of contemporary rescue PCI for failed thrombolysis shows a high use of coronary stents, Rheolytic thrombectomy, glycoprotein IIb/IIIa inhibitors, and intraaortic balloon pump placement. Angiographic and clinical success was high with low bleeding complications and low in-hospital mortality, suggesting that prospective, randomized trials using contemporary interventional therapy for rescue PCI be considered.
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Affiliation(s)
- David M Shavelle
- Division of Cardiology, Good Samaritan Hospital, Los Angeles, California 90017, USA.
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Gershlick AH, Stephens-Lloyd A, Hughes S, Abrams KR, Stevens SE, Uren NG, de Belder A, Davis J, Pitt M, Banning A, Baumbach A, Shiu MF, Schofield P, Dawkins KD, Henderson RA, Oldroyd KG, Wilcox R. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005; 353:2758-68. [PMID: 16382062 DOI: 10.1056/nejmoa050849] [Citation(s) in RCA: 338] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction remains unclear. There are few data comparing emergency percutaneous coronary intervention (rescue PCI) with conservative care in such patients, and none comparing rescue PCI with repeated thrombolysis. METHODS We conducted a multicenter trial in the United Kingdom involving 427 patients with ST-segment elevation myocardial infarction in whom reperfusion failed to occur (less than 50 percent ST-segment resolution) within 90 minutes after thrombolytic treatment. The patients were randomly assigned to repeated thrombolysis (142 patients), conservative treatment (141 patients), or rescue PCI (144 patients). The primary end point was a composite of death, reinfarction, stroke, or severe heart failure within six months. RESULTS The rate of event-free survival among patients treated with rescue PCI was 84.6 percent, as compared with 70.1 percent among those receiving conservative therapy and 68.7 percent among those undergoing repeated thrombolysis (overall P=0.004). The adjusted hazard ratio for the occurrence of the primary end point for repeated thrombolysis versus conservative therapy was 1.09 (95 percent confidence interval, 0.71 to 1.67; P=0.69), as compared with adjusted hazard ratios of 0.43 (95 percent confidence interval, 0.26 to 0.72; P=0.001) for rescue PCI versus repeated thrombolysis and 0.47 (95 percent confidence interval, 0.28 to 0.79; P=0.004) for rescue PCI versus conservative therapy. There were no significant differences in mortality from all causes. Nonfatal bleeding, mostly at the sheath-insertion site, was more common with rescue PCI. At six months, 86.2 percent of the rescue-PCI group were free from revascularization, as compared with 77.6 percent of the conservative-therapy group and 74.4 percent of the repeated-thrombolysis group (overall P=0.05). CONCLUSIONS Event-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment. Rescue PCI should be considered for patients in whom reperfusion fails to occur after thrombolytic therapy.
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Affiliation(s)
- Anthony H Gershlick
- Department of Cardiology, University Hospitals of Leicester, Leicester, United Kingdom.
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Sutton AGC, Campbell PG, Graham R, Price DJA, Gray JC, Grech ED, Hall JA, Harcombe AA, Wright RA, Smith RH, Murphy JJ, Shyam-Sundar A, Stewart MJ, Davies A, Linker NJ, de Belder MA. One year results of the Middlesbrough early revascularisation to limit infarction (MERLIN) trial. Heart 2005; 91:1330-7. [PMID: 16162629 PMCID: PMC1769146 DOI: 10.1136/hrt.2004.047753] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To report one year results of the MERLIN (Middlesbrough early revascularisation to limit infarction) trial, a prospective randomised trial comparing the strategy of coronary angiography and urgent revascularisation with conservative treatment in patients with failed fibrinolysis complicating ST segment elevation myocardial infarction (STEMI). The 30 day results have recently been published. At the planning stage of the trial, it was determined that follow up of trial patients would continue annually to three years to determine whether late benefit occurred. SUBJECTS 307 patients who received a fibrinolytic for STEMI but failed to reperfuse early according to previously described ECG criteria and did not develop cardiogenic shock. METHODS Patients were randomly assigned to receive either emergency coronary angiography with a view to proceeding to urgent revascularisation (rescue percutaneous coronary intervention (rPCI) arm) or continued medical treatment (conservative arm). The primary end point was all cause mortality at 30 days. The secondary end points included the composite end point of death, reinfarction, stroke, unplanned revascularisation, or heart failure at 30 days. The same end points were evaluated at one year and these results are presented. RESULTS All cause mortality at one year was similar in the conservative arm and the rPCI arm (13.0% v 14.4%, p = 0.7, risk difference (RD) -1.4%, 95% confidence interval (CI) -9.3 to 6.4). The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularisation, or heart failure was significantly higher in the conservative arm (57.8% v 43.1%, p = 0.01, RD 14.7%, 95% CI 3.5% to 25.5%). This was driven almost exclusively by a significantly higher incidence of subsequent unplanned revascularisation in the conservative arm (29.9% v 12.4%, p < 0.001, RD 17.5%, 95% CI 8.5% to 26.4%). Reinfarction and clinical heart failure were numerically, but not statistically, more common in the conservative arm (14.3% v 10.5%, p = 0.3, RD 3.8%, 95% CI -3.7 to 11.4, and 31.2% v 26.1%, p = 0.3, RD 5.0%, 95% CI -5.1 to 15.1). There was a strong trend towards fewer strokes in the conservative arm (1.3% v 5.2%, p = 0.06, RD -3.9%, 95% CI -8.9 to 0.06). CONCLUSION At one year of follow up, there was no survival advantage in the rPCI arm compared with the conservative arm. The incidence of the composite secondary end point was significantly lower in the rPCI arm, but this was driven almost entirely by a highly significant reduction in the incidence of further revascularisation.
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Affiliation(s)
- A G C Sutton
- The James Cook University Hospital, Middlesbrough TS4 3BW, UK.
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Tadros GM, Iliadis EA, Wilson RF, Henry TD. The evolving role of rescue therapy for acute myocardial infarction. Future Cardiol 2005; 1:473-8. [PMID: 19804147 DOI: 10.2217/14796678.1.4.473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Coronary reperfusion for acute ST-elevation myocardial infarction can be accomplished with fibrinolytic therapy or with percutaneous coronary intervention (PCI). Primary PCI provides more effective and sustained early reperfusion than fibrinolytic therapy, but is only available in a minority of hospitals worldwide. There is a lack of a definite method for identification of patients who have inadequate reperfusion after fibrinolysis. Transfer of patients after fibrinolysis for diagnostic angiography and possible rescue therapy is safe and feasible. Rescue PCI with the use of stents and antiplatelet therapy decreases cardiovascular mortality and morbidity compared with conservative therapy. Increasing use of primary PCI and forming networks to transfer patients to centers that offer primary PCI may decrease the need for rescue therapy in the future.
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Affiliation(s)
- George M Tadros
- University of Minnesota, Division of Cardiology,420 Delaware Street East, MMC 508Minneapolis, MN 55455, USA.
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Steg PG, Francois L, Iung B, Himbert D, Aubry P, Charlier P, Benamer H, Feldman LJ, Juliard JM. Long-term clinical outcomes after rescue angioplasty are not different from those of successful thrombolysis for acute myocardial infarction. Eur Heart J 2005; 26:1831-7. [PMID: 15930039 DOI: 10.1093/eurheartj/ehi331] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS The long-term value of rescue percutaneous transluminal coronary angioplasty (PTCA) in patients with ST-segment elevation myocardial infarction who received thrombolytic therapy but failed to achieve early recanalization of the artery is still debated. This study aimed to compare long-term outcomes after successful thrombolysis vs. systematic attempted rescue PTCA. METHODS AND RESULTS A total of 362 consecutive patients with STEMI hospitalized within 6 h of symptom onset and treated with intravenous thrombolytic therapy were studied. Of these, 345 underwent coronary angiography within 90 min. Sixty per cent of patients achieved TIMI 3 flow and were treated medically; the in-hospital death rate in this group was 4%. Nine per cent of patients had TIMI 2 flow and 31% TIMI 0-1 flow. In this latter group, rescue PTCA was attempted in 85.8% with a hospital death rate of 5.5% (20% with failed vs. 4% with successful rescue PTCA, P=0.03). Eight year actuarial survival without recurrent myocardial infarction was no different in patients who had successful thrombolytic therapy and in patients with attempted rescue PTCA [78 and 95% CI (71-85) vs. 78 and 95% CI (68-87), respectively, hazard ratio: 0.93 (0.52-1.65), P=0.80]. Total mortality, cardiac mortality, and other composite endpoints also did not differ between groups. CONCLUSION Routine attempted rescue PTCA 90 min after thrombolytic therapy in patients with persistent occlusion of the infarct-related vessels achieves long-term clinical outcomes which do not differ from those obtained by successful thrombolysis.
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Affiliation(s)
- Philippe Gabriel Steg
- Department of Cardiology, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75877 Paris Cedex 18, France.
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García E. Intervencionismo en el contexto del infarto de miocardio. Conceptos actuales. Rev Esp Cardiol 2005. [DOI: 10.1157/13074847] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Reperfusion treatment of ST-segment elevation myocardial infarction (STEMI) is one of the medical interventions with the largest potential for saving human lives, independently of age and gender. An attempt to reopen an acutely occluded coronary artery can be done within a wide array of possibilities, from the simple administration of aspirin to the combination of drugs and complex coronary artery interventions. Fibrinolytic drugs and aspirin represent the easiest way to attempt reperfusion and together offer an acceptable compromise between opportunity for treatment and efficacy. Other drugs and the use of invasive revascularization alternatives yield further advantages, and in some high-risk subgroups may be the most rational treatment approach. Beyond investigator's bias and dedication to either form of reperfusion treatment, interventions and/or drugs should be used as needed (and as possible) to increase the overall impact of reperfusion treatment in the community, taking advantage of the best potential of each approach. Most resources have been directed toward the improvement of reperfusion rates with the combination of fibrinolytic and antiplatelet drugs or with angioplasty. These efforts have certainly raised costs, but have not decisively improved clinical outcome nor have they broadened the impact of reperfusion treatment in the community. Indeed, the main shortcoming of reperfusion therapy is that the cohort of untreated patients is still larger than the cohort of treated patients. At a time when mortality of patients with STEMI reaching the hospital and receiving treatment has decreased significantly, the prehospital diagnosis and treatment of STEMI with the objective of enlarging the treated population and shortening the pretreatment delays is likely the best strategy to further reduce mortality. The need for a population approach to treatment of STEMI is even more obvious when considering the expanding patient load that continuously worsens its clinical risk profile, together with the increasing incidence of diabetes, obesity, hypertension, and smoking habits. The target for improving reperfusion treatment of STEMI in the future, and thereby saving more lives, seems now to involve a cultural change and fulfillment of an organizational mission more than an incremental improvement in the current pharmacologic or interventional approach. These epidemiologic and social aspects of contemporary medicine deserve full attention at a time when researchers, clinicians, and health care providers tend to focus primarily on technological advances.
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Affiliation(s)
- Flavio Ribichini
- Division of Cardiology Universita del Piemonte Orientale, Ospedale Maggiore della Carita, Novara, Italy
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A randomized trial of coronary stenting versus balloon angioplasty as a rescue intervention after failed thrombolysis in patients with acute myocardial infarction. J Am Coll Cardiol 2004; 44:2073-9. [DOI: 10.1016/j.jacc.2004.09.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Accepted: 09/13/2004] [Indexed: 11/21/2022]
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Heggunje PS, Harjai KJ, Stone GW, Mehta RH, Marsalese DL, Boura JA, O'Neill WW, Grines CL. Procedural success versus clinical risk status in determining discharge of patients after primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 2004; 44:1400-7. [PMID: 15464319 DOI: 10.1016/j.jacc.2004.06.065] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2004] [Revised: 06/17/2004] [Accepted: 06/22/2004] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We evaluated whether patients' clinical status, angioplasty success, or both, should guide discharge after primary angioplasty (i.e., percutaneous coronary intervention [PCI]) for acute myocardial infarction (AMI). BACKGROUND Current guidelines do not address a discharge strategy for AMI patients undergoing successful PCI. METHODS Patients who underwent PCI in Primary Angioplasty in Myocardial Infarction (PAMI) studies (N = 3,188) were classified as "high clinical risk" if they had either age >70 years, Killip class >1, heart rate >100 beats/min, systolic blood pressure <100 mm Hg, anterior MI, or left bundle branch block, and as "low clinical risk" if none was present. Successful PCI patients were compared with those with unsuccessful PCI in both groups for 30-day major adverse cardiac events (MACE). RESULTS Percutaneous coronary intervention was successful in 668 (90%) of 745 low-risk clinical and 2,104 (86%) of 2,443 high-risk clinical patients. Regardless of clinical risk status, patients with successful PCI had lower 30-day MACE than those with unsuccessful PCI (low-risk group: 4.6% vs. 22%, p < 0.0001; high-risk group: 7% vs. 21%; p < 0.0001). Moreover, successful PCI patients with either risk status had few MACE after day 4, whereas unsuccessful PCI patients had more MACE. The success of PCI was the strongest independent predictor of 30-day MACE (odds ratio [OR] 3.7, 95% confidence interval [CI] 2.8 to 5.0). A constellation of three or more high-risk clinical features also predicted higher 30-day MACE (OR 2.25, 95% CI 1.62 to 3.12). CONCLUSIONS The success of PCI is the prime determinant of clinical outcome after PCI for AMI. The majority of AMI patients with less than three high-risk clinical features who undergo successful PCI may be discharged from the hospital by day 4. In contrast, patients with more than two high-risk clinical features or unsuccessful PCI may need longer observation.
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Gibson CM, Murphy SA, Morrow DA, Aroesty JM, Gibbons RJ, Gourlay SG, Barron HV, Giugliano RP, Antman EM, Braunwald E. Angiographic perfusion score: an angiographic variable that integrates both epicardial and tissue level perfusion before and after facilitated percutaneous coronary intervention in acute myocardial infarction. Am Heart J 2004; 148:336-40. [PMID: 15309006 DOI: 10.1016/j.ahj.2003.12.044] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Both epicardial and myocardial perfusion have been associated with clinical outcomes in the setting of ST elevation myocardial infarction (STEMI), and the performance of adjunctive/rescue percutaneous coronary intervention (PCI) may further improve clinical outcomes after fibrinolytic administration. METHODS The goal was to develop a simple, broadly applicable angiographic metric that takes into account indices of epicardial and myocardial perfusion both before and after PCI to arrive at a single perfusion grade in patients undergoing cardiac catheterization after fibrinolysis. The angiographic perfusion score (APS) is the sum of the Thrombolysis in Myocardial Infarction (TIMI) flow grade (TFG; 0-3) added to the TIMI myocardial perfusion grade (TMPG; 0-3) before and after PCI (total possible grade, 0-12). Failed perfusion was defined as an APS of 0 to 3, partial perfusion was defined as an APS of 4 to 9, and full perfusion was defined as an APS of 10 to 12. The APS was evaluated in patients from the Double-blind, Placebo-contolled, Multicenter Angiographic Trial of Rhumab CD18 in Acute Myocardial Infarction (LIMIT-AMI; n = 394) and Enoxaparin as Adjunctive Antithrombin Therapy for ST-Elevation Myocardial Infarction-Thrombolysis In Myocardial Infarction (ENTIRE-TIMI) 23 trials (n = 483), and infarct size (120-216 hours after AMI SPECT Technetium-99m Sestamibi data) was assessed in the LIMIT-AMI trial. RESULTS The APS was associated with the incidence of death or myocardial infarction (failed, 16.7% [n = 18]; partial, 2.5% [n = 155]; full, 2.4% [n = 82]; P =.039 for trend) and larger SPECT infarct sizes (failed, median 39% [n = 10]; partial, 12% [n = 79]; and full, 8% [n = 35]; P =.002). No patient with full APS died, whereas the mortality rate was 11.1% in patients with a failed APS (P =.03). CONCLUSIONS The APS combines grades of epicardial and tissue level perfusion before and after PCI or at the end of diagnostic cardiac catheterization to arrive at a single angiographic variable that is associated with infarct size and the rates of 30-day death or MI. Partial or full angiographic perfusion scores are associated with a halving of infarct size, and no patients with full angiographic perfusion died.
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Affiliation(s)
- C Michael Gibson
- TIMI Study Group, the Department of Medicine, Brigham & Women's Hospital, Boston, Mass., USA
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Sutton AGC, Campbell PG, Graham R, Price DJA, Gray JC, Grech ED, Hall JA, Harcombe AA, Wright RA, Smith RH, Murphy JJ, Shyam-Sundar A, Stewart MJ, Davies A, Linker NJ, de Belder MA. A randomized trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST-segment elevation myocardial infarction. J Am Coll Cardiol 2004; 44:287-96. [PMID: 15261920 DOI: 10.1016/j.jacc.2003.12.059] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2003] [Revised: 12/05/2003] [Accepted: 12/10/2003] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to compare emergency coronary angiography with or without rescue percutaneous coronary intervention (PCI) with conservative treatment in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction (STEMI). BACKGROUND Most patients with STEMI receive fibrinolytic therapy and aspirin. The management of failed fibrinolysis is unclear. METHODS A total of 307 patients with STEMI and failed fibrinolysis were randomized to emergency coronary angiography with or without rescue PCI or conservative treatment. RESULTS Thirty-day all-cause mortality was similar in the rescue and conservative groups (9.8% vs. 11%, p = 0.7, risk difference [RD] 1.2%, 95% confidence interval [CI] -5.8 to 8.3). The composite secondary end point of death/re-infarction/stroke/subsequent revascularization/heart failure occurred less frequently in the rescue group (37.3% vs. 50%, p = 0.02, RD 12.7%, 95% CI 1.6 to 23.5), driven by less subsequent revascularization (6.5% vs. 20.1%, p < 0.01, RD 13.6%, 95% CI 6.2 to 21.4). Re-infarction and clinical heart failure were less common in the rescue group (7.2% vs. 10.4%, p = 0.3, RD 3.2%, 95% CI -3.3 to 9.9; and 24.2% vs. 29.2%, p = 0.3, RD 5.7%, 95% CI -4.3 to 15.6, respectively). Strokes and transfusions were more common in the rescue group (4.6% vs. 0.6%, p = 0.03, RD 3.9%, 95% CI 0.5 to 8.6; and 11.1% vs. 1.3%, p < 0.001, RD 9.8%, 95% CI 4.9 to 19.9, respectively). Left ventricular function at 30 days was the same in the two groups. CONCLUSIONS Rescue angioplasty did not improve survival by 30 days, but improved event-free survival, almost completely due to a reduction in subsequent revascularization. Rescue angioplasty was associated with more strokes and more transfusions and did not result in preservation of left ventricular systolic function at 30 days.
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Alhadi HA, Fox KAA. Do we need additional markers of myocyte necrosis: the potential value of heart fatty-acid-binding protein. QJM 2004; 97:187-98. [PMID: 15028848 DOI: 10.1093/qjmed/hch037] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Heart fatty-acid-binding protein (FABP) is a small cytosolic protein that is abundant in the heart and has low concentrations in the blood and in tissues outside the heart. It appears in the blood as early as 1.5 h after onset of symptoms of infarction, peaks around 6 h and returns to baseline values in 24 h. These features of H-FABP make it an excellent potential candidate for the detection of acute myocardial infarction (AMI). We review the strengths and weaknesses of H-FABP as a clinically applicable marker of myocyte necrosis in the context of acute coronary syndromes.
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Affiliation(s)
- H A Alhadi
- Cardiovascular Research Unit, Centre for Cardiovascular Science, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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Syed MA, Borzak S, Asfour A, Gunda M, Obeidat O, Murphy SA, Gibbons RJ, Gourlay SG, Barron HV, Weaver WD, Hudson M. Single lead ST-segment recovery: a simple, reliable measure of successful fibrinolysis after acute myocardial infarction. Am Heart J 2004; 147:275-80. [PMID: 14760325 DOI: 10.1016/j.ahj.2003.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Successful reperfusion after acute ST-elevation myocardial infarction improves prognosis. Among the different electrocardiographic markers of reperfusion, sum ST resolution is considered the hallmark of reperfusion, but is cumbersome to use. METHODS To assess the usefulness of a single lead ST resolution at 90 minutes after fibrinolysis compared with the sum ST resolution in predicting Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow, we used prospectively collected data from the Limitation of Myocardial Injury Following Thrombolysis in Acute Myocardial Infarction (LIMIT-AMI) study. All patients had electrocardiograms recorded at presentation and 90 minutes and a coronary angiogram 90 minutes after fibrinolysis. RESULTS Infarction artery patency was assessed in 238 patients with 4 different ST resolution criteria: single lead ST resolution > or =50% and > or =70% and sum ST resolution > or =50% and > or =70%. The most sensitive criteria for TIMI grade 3 flow was single lead ST resolution > or =50% (sensitivity rate, 70%; specificity rate, 54%), whereas sum ST resolution > or =70% was most the specific criteria (sensitivity rate, 45%; specificity rate, 79%). The proportion of patients with TIMI grade 3 flow was similar in all 4 ST resolution groups (P =.84). Pre-discharge infarction size and ejection fraction were also similar. No single lead or sum lead measure of ST resolution was significantly associated with an increased risk of death, heart failure, or reinfarction. CONCLUSION We propose that single lead ST-resolution > or =50% as an optimal electrocardiographic indicator for successful reperfusion 90 minutes after fibrinolysis. This simple electrocardiographic measure should be combined with bedside clinical and hemodynamic assessment to optimize decision making after fibrinolysis.
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Affiliation(s)
- Mushabbar A Syed
- Henry Ford Heart and Vascular Institute, Detroit, Mich 48202, USA
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La Vecchia L, Favero L, Martini M, Vincenzi P, Rubboli A, Ottani F, Bottero M, Fontanelli A. Systematic coronary stenting after failed thrombolysis in high-risk patients with acute myocardial infarction: procedural results and long-term follow-up. Coron Artery Dis 2003; 14:395-400. [PMID: 12878905 DOI: 10.1097/01.mca.0000085136.16622.33] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Stenting in acute myocardial infarction (AMI) represents a feasible and effective revascularization strategy. However, very little information is available for patients who receive a stent after failed thrombolysis (so-called 'rescue' stenting). METHODS We analysed the procedural results and the 2-year follow-up of all consecutive patients with moderate-to-large AMI treated with rescue stenting in the period 1996-2001. RESULTS The study cohort includes 123 patients (mean age 60+/-12 years, 78% men). Coronary angiography showed multivessel disease in 47% of patients; the infarct-related vessel was the left anterior descending coronary artery in 47%, the right coronary artery in 41%, the left circumflex coronary artery in 9.5% and a saphenous vein graft in 2.5%. Baseline Thrombolysis in Myocardial Infarction (TIMI) flow was grade 0-1 in 65% and grade 2 in 25%. Coronary stenting was attempted in all 123 patients and was successful in 119 out of 123 (96.7%); abciximab was used in 57 out of 123 (46%) and intra-aortic balloon pumping in 35 out of 123 (28%). At the end of the procedure, TIMI 3 flow was obtained in 104 out of 123 (85%) and TIMI 2 flow in 14 out of 123 (11%). There were 10 in-hospital deaths and four late deaths, with a long-term survival of 88.6%. This figure increases to 95.2% if patients presenting with cardiogenic shock are excluded. A new revascularization procedure was performed in 21% of discharged patients (in the target vessel for 12% and in non-target vessels for 9%). Overall, event-free survival at 2 years was 69%. At multivariate analysis, independent predictors of survival were age (P=0.014) and ejection fraction (P=0.006). CONCLUSIONS This report represents one of the first series concerning long-term follow-up after rescue stenting. The main results include a high procedural feasibility, a low late mortality and a target vessel revascularization rate in the range expected with stenting. These data must be viewed as part of the constant effort to optimize revascularization strategies in AMI.
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Ho TC, Ting CT, Liu TJ, Liang KW, Ho HY, Hsueh CW, Wang KY, Lin WW, Lee WL. Percutaneous coronary revascularization improves the prognosis of patients with cardiogenic shock in acute coronary syndrome: a chronological study. Int J Cardiol 2003; 89:135-43. [PMID: 12767535 DOI: 10.1016/s0167-5273(02)00432-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cardiogenic shock complicating acute coronary syndrome (ACS) implies grim prognosis with conventional management. Previous studies of coronary intervention yielded controversial results and were rarely analyzed chronologically. This study was to determine the impact of percutaneous coronary revascularization on outcome by studying two time periods 5 years apart in which the revascularization was more frequent and techniques more refined in the later period. METHODS AND MATERIALS All patients admitted to the intensive or coronary care unit for ACS in two 1.5-year study periods (Period I: Jan 1994-Jun 1995, Period II: Oct 1999-Apr 2000) were retrospectively screened. Patients who met strict criteria of cardiogenic shock within 24 h of ACS were enrolled. The demographics, management and in-hospital/3-month outcomes were analyzed. RESULTS Thirty-seven patients (33M/4F, aged 65+/-8 years) were enrolled in Period I and 32 patients (25M/7F, aged 68+/-13 years) in Period II. The incidence of cardiogenic shock was 11.8 and 9.3%, respectively. The demographics were similar except patients in Period II were older. Significantly more coronary angiography and interventions were done in the later period. The in-hospital (68 vs. 44%, P=0.047) and 3-month mortalities (70 vs. 44%, P=0.03) were significantly reduced in Period II. The in-hospital survivors in two study periods differed only in use of coronary angiography (94 vs. 50%, P=0.005) and interventions (83 vs. 33%, P=0.005) but not others. CONCLUSIONS Percutaneous coronary revascularization does improve the clinical outcome of cardiogenic shock when analyzed chronologically. This treatment is warranted in every such patient in the interventional era.
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Affiliation(s)
- Tung-Ching Ho
- Division of Cardiology, Department of Medicine, Taichung Veterans General Hospital, 160, Sector 3, Chung-Kang Road, 407, Taichung, Taiwan
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Hong YJ, Jeong MH, Lee SH, Park OY, Jeong WK, Lee SR, Kim W, Rhew JY, Lee SH, Ahn YK, Cho JG, Ahn BH, Park JC, Kim SH, Kang JC. The long-term clinical outcomes after rescue percutaneous coronary intervention in patients with acute myocardial infarction. J Interv Cardiol 2003; 16:209-16. [PMID: 12800398 DOI: 10.1034/j.1600-0854.2003.8048.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rescue percutaneous coronary intervention (PCI) has been used to treat patients after failed thrombolysis in acute myocardial infarction. However, the short- and long-term benefits of rescue PCI have not been known exactly. The goal of this study was to examine the clinical and angiographic outcomes, the success rate of the procedure, and the long-term survival rate after rescue PCI. The clinical and angiographic outcomes of 31 patients (Group I; 59.7 +/- 11.4 years, 80.6% male), who underwent rescue PCI were compared with those of 177 patients (Group II; 59.7 +/- 9.7 years, 79.7% male), who underwent primary PCI at Chonnam National University Hospital between January 1997 and December 1999. There were no significant differences in the risk factors for coronary artery diseases except for smoking (Group I; 24/31, 77.4% vs. Group II; 76/177, 42.9%, P = 0.011). The incidence of cardiogenic shock was higher in Group I than in Group II (Group I; 7/31, 22.6% vs. Group II; 11/177, 6.2%, P = 0.021). The coronary angiographic findings were not different between two groups, except for Thrombolysis in Myocardial Infarction (TIMI) flow of Group I was lower than in Group II (Group I; 1.14 +/- 0.93 vs. Group II; 1.61 +/- 1.14, P = 0.001). The primary success rate was 93.6% (29/31) in Group I and 94.9% (168/177) in Group II (P = 0.578). The baseline ejection fraction was lower in Group I than in Group II (Group I; 44.2 +/- 8.9% vs. Group II; 50.8 +/- 11.7, P = 0.023), which improved in both groups (Group I; 51.7 +/- 7.9% vs. Group II; 60.7 +/- 13.4%, P = 0.001 respectively) at 6 months after the procedures. The survival rates of Group I were 93.5%, 93.5%, and 90.3% and those of Group II were 94.5%, 93.7%, and 91% at 1, 6, and 12 months, respectively. Rescue PCI is associated with the risk factor of smoking. The indication for rescue PCI was more common in patents with cardiogenic shock. The success rate of rescue PCI was comparable to that of primary PCI, and left ventricular function is improved after rescue PCI on long-term clinical follow-up with relatively high survival rate.
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Affiliation(s)
- Young Joon Hong
- Heart Center of Chonnam National University Hospital, Research Institute of Medical Sciences, Chonnam National University, 8 Hak Dong, Dong Ku, Gwang Ju 501-757, Korea
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Katritsis D, Karvouni E, Webb-Peploe MM. Reperfusion in acute myocardial infarction: current concepts. Prog Cardiovasc Dis 2003; 45:481-92. [PMID: 12800129 DOI: 10.1053/pcad.2003.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Myocardial reperfusion is the treatment of choice in acute myocardial infarction. Pharmacological thrombolysis restores coronary artery patency in about two thirds of patients with acute myocardial infarction. However, mechanical reperfusion with primary angioplasty and stenting achieves higher patency rates with less complications, especially in high-risk patients. Adjunctive pharmacotherapy and new device technology may improve the outcome of primary angioplasty. Facilitated angioplasty using a combination of half-dose thrombolysis, platelet glycoprotein IIb/IIIa antagonists, and early intervention, appears to be a promising strategy for the treatment of acute myocardial infarction in the modern era. The efficacy and safety of this approach are currently evaluated in several ongoing trials.
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Poloński L, Gasior M, Wasilewski J, Wilczek K, Wnek A, Adamowicz-Czoch E, Sikora J, Lekston A, Zebik T, Gierlotka M, Wojnar R, Szkodziński J, Kondys M, Szyguła-Jurkiewicz B, Wołk R, Zembala M. Outcomes of primary coronary angioplasty and angioplasty after initial thrombolysis in the treatment of 374 consecutive patients with acute myocardial infarction. Am Heart J 2003; 145:855-61. [PMID: 12766744 DOI: 10.1016/s0002-8703(02)94823-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In patients with acute myocardial infarction (MI), the efficacy of thrombolysis is low. Angioplasty after failed thrombolysis (rescue percutaneous coronary angioplasty [PTCA]) has been associated with an increase in the incidence of inhospital complications. It has been proposed that these complications result from the procedure itself. Thus, the aim of this study was to compare the efficacy, inhospital complications, and mortality rate of patients with MI who are treated with primary PTCA and PTCA after initial thrombolysis (rescue or immediate rescue) in an experienced clinical center specializing in percutaneous coronary interventions. METHODS AND RESULTS The study group consisted of consecutive patients with MI treated with primary PTCA (n = 195) or PTCA after initial thrombolysis (n = 179). The study was performed in a referral center with a 24-hour catheter-laboratory service. The success rate of the procedure was 90.5% and 88.2% in the PTCA after initial thrombolysis group and primary PTCA group, respectively. The groups did not differ in the frequency of reocclusion, emergency surgical revascularization (coronary artery bypass grafting), or stroke. In patients without cardiogenic shock, the inhospital mortality rates were 3.2% and 0.6% in the rescue and immediate rescue group and primary PTCA group, respectively (not significant). In a subgroup of patients with cardiogenic shock, the mortality rate was 36.0% in the initial thrombolysis PTCA group and 30.8% in the primary PTCA group. However, after successful PTCA in this subgroup, the mortality rate dropped to 18% and 10%, respectively. CONCLUSIONS After initial thrombolysis, PTCA is safe, effective, and likely to restore grade 3 Thrombolysis In Myocardial Infarction flow in about 90% of patients. When available, immediate rescue PTCA should be performed in all patients, including patients with cardiogenic shock.
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Affiliation(s)
- Lech Poloński
- Third Department of Cardiology of the Silesian School of Medicine, Zabrze, Poland.
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Fiol M, Carrillo A, Velasco J. La disponibilidad de la cardiología intervencionista y su relación con el pronóstico de los pacientes con infarto agudo de miocardio tratados con fibrinólisis. Med Intensiva 2003. [DOI: 10.1016/s0210-5691(03)79936-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Modern management of acute myocardial infarction. Curr Probl Cardiol 2003. [DOI: 10.1016/s0146-2806(03)70001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Cooper HA, de Lemos JA, Morrow DA, Sabatine MS, Murphy SA, McCabe CH, Gibson CM, Antman EM, Braunwald E. Minimal ST-segment deviation: a simple, noninvasive method for identifying patients with a patent infarction-related artery after fibrinolytic administration. Am Heart J 2002; 144:790-5. [PMID: 12422146 DOI: 10.1067/mhj.2002.125618] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Because rescue intervention may improve the outcome of patients who fail to achieve epicardial reperfusion after fibrinolytic administration for acute ST-elevation myocardial infarction (STEMI), simple noninvasive measures of infarction-related artery (IRA) patency are needed. The sum of ST-segment resolution (sum-STRES) has a high positive predictive value (PPV) for a patent IRA, but is quite time-consuming. METHODS We retrospectively developed a very simple assessment that requires only the measurement of ST-segment deviation in a single electrocardiographic lead on a single electrocardiogram (ECG) 90 minutes after fibrinolytic administration. The ECG obtained immediately before fibrinolytic administration was reviewed as a means of selecting the single lead with the greatest ST-segment deviation. The absolute magnitude of ST deviation was measured in this lead on the 90-minute ECG. Minimal ST-segment deviation (MSTD) was defined as < or =1 mm ST deviation for inferior infarctions and < or =2 mm ST deviation for anterior infarctions. We compared the predictive value of this method with established but more complex ECG methods using data from the Thrombolysis In Myocardial Infarction (TIMI) 14 trial of low-dose fibrinolytic with full-dose glycoprotein IIb/IIIa inhibition. RESULTS Of the 604 patients with an evaluable ECG and angiographic data, 383 (63%) had MSTD. The presence of MSTD had a positive predictive value (PPV) of 91% for a patent IRA (TIMI flow grade 2 or 3). Results were similar for inferior and anterior infarctions. MSTD was a means of identifying 90% of patients with complete sum-STRES. The PPV of MSTD compared favorably with that of standard measures of ST-segment resolution, but it required only a few seconds to perform. CONCLUSIONS The presence of MSTD at 90 minutes after fibrinolytic administration indicates a very high likelihood of IRA patency. MSTD may be helpful in identifying patients with STEMI treated by means of fibrinolytics who could safely avoid emergent coronary angiography.
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Affiliation(s)
- Howard A Cooper
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass 02115, USA.
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Balachandran KP, Miller J, Pell ACH, Vallance BD, Oldroyd KG. Rescue percutaneous coronary intervention for failed thrombolysis: results from a district general hospital. Postgrad Med J 2002; 78:330-4. [PMID: 12151685 PMCID: PMC1742391 DOI: 10.1136/pmj.78.920.330] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the outcome of a policy of emergency percutaneous coronary intervention (PCI) in patients with acute myocardial infarction and electrocardiographic (ECG) evidence of failed reperfusion after thrombolysis. DESIGN Observational study. SETTING District general hospital. PATIENTS A total of 109 consecutive patients with acute myocardial infarction who underwent emergency angiography and angioplasty for failed reperfusion diagnosed on the basis of standard ECG criteria. MAIN OUTCOME MEASURES In-hospital mortality; death, infarct territory reinfarction, and reintervention by PCI or coronary artery bypass graft (CABG) during follow up; in-lab resource utilisation. RESULTS At initial angiography, 76 patients had Thrombolysis in Myocardial Infarction (TIMI) trial 0/1 flow and 33 had TIMI 2/3 flow. Fourteen patients were in cardiogenic shock. TIMI 3 flow was established or maintained in 93 patients (85%). Overall in-hospital mortality was 9%. It was 3% in non-shock patients, 50% in shocked patients, and 40% when the procedure was unsuccessful (TIMI 0/1 flow post-procedure). Over a mean follow up of 30 months (>12 months of follow up in all patients) there were 19 further events (one death, five reinfarctions, and 13 revascularisations (nine CABG and four PCI)). The cost of rescue PCI was not significantly higher than comparable elective interventions. CONCLUSION A policy of emergency angiography and PCI for failed reperfusion in acute myocardial infarction can be carried out in a hospital without on-site surgical backup with good medium term clinical outcomes.
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Affiliation(s)
- K P Balachandran
- Lanarkshire Cardiac Catheterisation Laboratories, Hairmyres Hospital, Eaglesham Road, East Kilbride G75 8RG, UK
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Nagao K, Hayashi N, Kanmatsuse K, Kikuchi S, Ohuba T, Takahashi H. An early and complete reperfusion strategy for acute myocardial infarction using fibrinolysis and subsequent transluminal therapy--The FAST trial. Circ J 2002; 66:576-82. [PMID: 12074277 DOI: 10.1253/circj.66.576] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The efficacy and safety of fibrinolysis and subsequent transluminal (FAST) therapy were evaluated in 195 patients with acute myocardial infarction (AMI) for the early achievement of thrombolysis-in-myocardial-infarction grade 3 (TIMI-3) flow in the infarct-related artery. Intravenous thrombolysis using the optimal dose of a thrombolytic agent was initiated immediately after arrival in the emergency room, followed by coronary angiography and adjuvant percutaneous coronary intervention. A comparison of the thrombolysis alone (n=83) and thrombolysis plus intervention (n=112) groups showed significant differences in the time interval from hospital arrival to achievement of TIMI-3 flow (66.2+/-23.7 vs 111.6+/-29.6 min, p<0.0001), creatine kinase-MB release (295+/-201 vs 468+/-322 U/L, p=0.0003) and peak troponin T (23.6+/-16.9 vs 38.9+/-25.9 ng/ml, p<0.0001). No significant differences were observed in either 30-day mortality or complications. The TIMI-3 flow at the initial angiography was significantly higher with a single bolus of mutant tissue-type plasminogen activator (t-PA) monteplase than with an accelerated infusion of t-PA (60% vs 32%, p=0.005). In conclusion, the early restoration of TIMI-3 flow by FAST therapy reduced the degree of myocardial damage with a low risk of complications. TIMI-3 flow was achieved at an earlier stage with monteplase and this agent may be beneficial in the FAST therapy.
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Affiliation(s)
- Ken Nagao
- Department of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
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Gill S, Haastrup B, Haghfelt T, Dellborg M, Clemmensen P. Continuous vectorcardiography is superior to standard electrocardiography in the prediction of long-term outcome after thrombolysis in patients with acute myocardial infarction. Coron Artery Dis 2002; 13:169-75. [PMID: 12131021 DOI: 10.1097/00019501-200205000-00006] [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: 11/26/2022]
Abstract
BACKGROUND Thrombolytic therapy results in reperfusion of the occluded coronary vessel in approximately 75% of treated patients with acute myocardial infarction (AMI). Unsuccessful thrombolysis results in impaired outcome. This study was undertaken to evaluate reperfusion assessments with 12-lead standard static electrocardiography (ECG) and continuous vectorcardiography (VCG) in AMI patients treated with thrombolytic therapy, with particular emphasis on the value of these assessments in relation to long-term outcome. METHODS ST-recovery analysis 90 and 180 min after the start of thrombolytic therapy was performed by repeated ECG and by VCG in 63 AMI patients. Median follow-up was 255 days. RESULTS No significant differences in long-term outcome were found between patients with or without obtained reperfusion, as assessed by ECG. For VCG, we found significant elevated relative risks for experiencing death (relative risk = 11.00, confidence interval = 2.70-44.90); P = 0.0008 for the group with ST-vector magnitude recovery of less than 50% at 90 min from start of thrombolytic therapy. CONCLUSION We demonstrated that early reperfusion assessment with VCG enables the prediction of long-term outcome and is superior to reperfusion assessment with standard static ECG in this regard. We therefore recommend continuous ischemia monitoring of AMI patients treated with thrombolytic therapy as a routine procedure.
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Affiliation(s)
- Sabine Gill
- Department of Cardiology, Odense University Hospital, Odense, Denmark.
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Abstract
The acute coronary syndromes (ACS) have in common rupture of a vulnerable plaque, leading to exposure of the subendothelial surface and plaque core. The resultant thrombosis leads to a variable degree of flow occlusion, the extent of which differentiates the three syndromes and their treatment by percutaneous coronary intervention (PCI). The guiding principle in the decision when to use PCI in the ACS is that the more time critical and high risk the clinical situation, the more likely it is that PCI will improve ultimate outcome. The use of risk stratification by clinical variables can lead to better triage of patients with non-ST-elevation myocardial infarction (MI) and unstable angina between PCI and medical management. Patients presenting with symptoms suggestive of prolonged ischemia should have an electrocardiogram searching for ST changes, a targeted physical, and blood drawn for rapid assay of cardiac enzymes. In the event that ST elevations suggest infarction, while medical therapy is initiated, emergency cardiac catheterization can be organized. PCI in ACS requires adjunctive antiplatelet and antithrombin therapy, and, in general, coronary stenting is advisable. Among patients with non-ST-elevation MI or unstable angina who can be medically stabilized, the presence of high clinical risk scores would favor early coronary angiography. In their absence, medical therapy can be pursued, unless recurrent ischemia occurs. When the patient's condition is stable, evaluation by stress testing can be used to guide further decisions.
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Affiliation(s)
- Gilbert L Raff
- Division of Cardiology, Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI 48073, USA
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Arora UK, Conde I, Kleiman NS. Glycoprotein IIb/IIIa antagonists in the setting of rescue percutaneous coronary intervention. J Interv Cardiol 2002; 15:155-62. [PMID: 12063811 DOI: 10.1111/j.1540-8183.2002.tb01048.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
It is clear that survival and better outcomes after acute myocardial infarction (AMI) are dependent on rapid, complete, and sustained reperfusion of the affected myocardium. Thrombolytic therapy is currently the most common reperfusion strategy in AMI, however, a significant proportion of patients fail to reach reperfusion with this form of therapy. There is evidence from randomized trials that rescue percutaneous coronary intervention (PCI) for failed thrombolysis may convey better outcomes to patients when compared to a conservative management. Nevertheless, it is not surprising that in this inherently thrombogenic milieu, rescue PCI has a lower success rate and a high incidence of rethrombosis, which have a profoundly negative impact on the outcome of patients. Platelets are thought to play a central role in the pathophysiology of failed thrombolysis and in the thrombotic complications following PCIs. Therefore, platelet glycoprotein (GP) IIb/IIIa antagonist may be of benefit in the setting of rescue PCI. Two retrospective subgroup analyses have suggested that these potent antiplatelet agents may improve the outcome of patients undergoing rescue PCI after failed full-dose thrombolytic therapy. An increase in major bleeding, however, has also been noted. Therefore, in light of the lack of evidence deriving from randomized, placebo-controlled trials, careful consideration of several aspects relevant to this setting is needed before GP IIb/IIIa antagonists are administered in rescue percutaneous coronary procedures.
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Affiliation(s)
- Umesh K Arora
- Department of Cardiology, Baylor College of Medicine, 6565 Fannin St., F-1090, Houston, TX 77030, USA
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