Coronary angioplasty performed within the thrombolysis in Myocardial Infarction II study

Complications of pericardiocentesis: A clinical synopsis

Pericardiocentesis (PC) is both a diagnostic and a potentially life-saving therapeutic procedure. Currently echocardiography-guided pericardiocentesis is considered the standard clinical practice in the treatment of large pericardial effusions and cardiac tamponade. Although considered relatively safe, this invasive procedure may be associated with certain risks and potentially serious complications. This review provides a summary of pericardiocentesis and a focused overview of the potential complications of this procedure.

[Acute coronary syndrome: unstable angina and myocardial infarction]

The acute coronary syndrome comprises unstable angina, non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction. A successful and stable revascularisation of the infarct related vessel, and the prevention of the loss of myocardium are the main therapeutic targets, as cardiovascular mortality and long term quality of life are essentially determined by left ventricular function. The clinical diagnosis comprises clinical symptoms, ECG-changes, and cardiac troponins. Early percutaneous coronary intervention (PCI) has become the most common method of coronary revascularisation. If PCI is not available, systemic thrombolysis is an alternative after exclusion of contraindications. Parenteral anticoagulation with intravenous or subcutaneous heparines, antithrombotic therapy and HMG-CoA reductase inhibitors are the common secondary drug therapy. Moreover, to prevent left ventricular remodelling ACE-inhibitors, angiotension 2-receptor antagonists, and beta-blocker are indicated.

Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study

To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569307 and an estimated diabetic population of 37932 (15505 men and 22427 women). The level of arterial reconstruction and associated risk factors were ascertained.

RESULTS

A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P<0.05) and were less frequently smokers (P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05).

CONCLUSION

Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Rheolytic thrombectomy during percutaneous revascularization for acute myocardial infarction: experience with the AngioJet catheter

BACKGROUND

Although balloon angioplasty and stenting are effective in the treatment of acute myocardial infarction (MI), reduced coronary flow and distal embolization frequently complicate interventions when thrombus is present. Adjunctive treatment with mechanical thrombectomy devices may reduce these complications.

METHODS AND RESULTS

We evaluated the angiographic and clinical outcomes of 70 patients with acute MI (16% with cardiogenic shock) and with angiographically evident thrombus who were treated with AngioJet rheolytic thrombectomy followed by immediate definitive treatment. Procedure success (residual diameter stenosis <50% and Thrombolysis in Myocardial Infarction [TIMI] flow > or =2 after final treatment) was achieved in 93.8%. Clinical success (procedure success without major in-hospital cardiac events) was achieved in 87.5%, with an in-hospital mortality rate of 7.1%. Final TIMI 3 flow was achieved in 87.7%. AngioJet treatment resulted in a mean thrombus area reduction from 73.2 +/- 64.6 mm(2) at baseline to 15.5 +/- 30.1 post-thrombectomy (P <.001). Subsequent definitive treatment included stenting in 67% and balloon angioplasty alone in 26% of patients. Procedural complications included distal embolization in six patients and perforation in two patients. There were no further major adverse events during 30-day follow-up.

CONCLUSION

Rheolytic thrombectomy can be performed safely and effectively in patients with acute MI, allowing for immediate definitive treatment in thrombus-containing lesions.

Improving the Efficacy and Stability of Coronary Reperfusion Following Thrombolysis: Exploring the Thrombin Hypothesis

A major assumption in the treatment of patients with acute myocardial infarction (MI) implies that the speed of coronary arterial reperfusion correlates directly with the overall extent of myocardial salvage, and that the extent of mycardial salvage, in turn, determines the absolute reduction in patient mortality. While a growing experience has made it clear that myocardial salvage-independent (time-independent) mechanisms of benefit also exist, few would argue with the hypothesis that the greatest benefit derived from coronary thrombolysis occurs with early (time-dependent) treatment. Thus, improvements in the efficacy of reperfusion and the stability of reperfusion are likely to have considerable impact on patient outcome.

Rescue angioplasty in the thrombolysis in myocardial infarction (TIMI) 4 trial

Rescue percutaneous transluminal coronary angioplasty (PTCA) has been used to establish reperfusion after failed thrombolysis, and the goal of this study was to examine the angiographic and clinical outcomes after rescue PTCA performed for an occluded artery 90 minutes after thrombolysis. Four hundred two patients with acute myocardial infarction were randomized to receive either anistreplase (APSAC), recombinant tissue plasminogen activator, or their combination in the Thrombolysis in Myocardial Infarction (TIMI) 4 trial. The angiographic and clinical outcomes of patients with a patent artery 90 minutes after thrombolysis were compared with those of patients with an occluded artery treated in a nonrandomized fashion with either rescue or no rescue PTCA. At 90 minutes, the number of frames required to opacify standard landmarks (corrected TIMI frame count) was significantly lower (i.e., flow was faster) after successful rescue PTCA (27 +/- 11) than that in patent arteries after successful thrombolysis (39 +/- 20, p < 0.001), and the incidence of TIMI grade 3 flow was correspondingly higher after successful rescue PTCA (87% vs 65%, p = 0.002). In-hospital adverse outcomes (death, recurrent acute myocardial infarction, severe congestive heart failure, cardiogenic shock or an ejection fraction <40%) occurred in 29% of successful rescue PTCAs and in 83% of failed rescue PTCAs (p = 0.01). Among all patients in whom rescue PTCA was performed (successes and failures combined), 35% of patients experienced an adverse outcome, which was the same as the 35% incidence observed in patients not undergoing rescue PTCA (p = NS) and tended to be higher than the 23% incidence observed in patients with patent arteries (p = 0.07). Although successful rescue PTCA for an occluded artery at 90 minutes results in restoration of flow that is superior to that of successful thrombolysis, the incidence of adverse events for the strategy of rescue PTCA as a whole was the same as that of undertaking no PTCA.

Heart disease in diabetes mellitus

The spectrum of heart disease in diabetic patients is broad and complex. This article discusses the epidemiologic associations between the two causes. It attempts to summarize the effects of diabetes at the cellular, vascular, and myocardial levels. The clinical manifestations are explored, and the treatment of heart disease as it pertains to diabetic patients is discussed.

Effect of delayed percutaneous transluminal coronary angioplasty of occluded coronary arteries after acute myocardial infarction

Whether angioplasty of occluded vessels after myocardial infarction may have beneficial effects on left ventricular function remains unknown. Patients with a first myocardial infarction and thrombolytic therapy who had an occluded infarct-related vessel at delayed coronary angiography were referred systematically for an elective coronary angioplasty performed between 3 and 4 weeks after the myocardial infarction. All patients underwent stress-redistribution-reinjection thallium-201 single-photon emission computed tomography for myocardial viability assessment. Prior angioplasty, a quantitative evaluation of global and regional left ventricular function, was performed. The study group consisted of 38 patients (aged 57 +/- 10 years); 18 had anterior wall infarctions and 20 inferior wall infarctions, but before angioplasty 3 had a patent artery and were excluded. Angioplasty was successful in 30 patients. At follow-up 13 patients (43%) had an occluded coronary artery. In contrast with patients with an occluded coronary artery at follow-up, those with a patent coronary artery had no left ventricular enlargement and had an improvement in both left ventricular ejection fraction (from 48 +/- 9% to 52 +/- 9.8%, p = 0.002) and regional wall motion index (delta = +0.95 SD, p <0.01). In patients with a patent vessel at follow-up, there was a positive correlation between the number of myocardial viable segments and improvement of the infarct zone wall motion (r = 0.52; p = 0.035), and the number of necrotic segments at baseline was positively correlated to the 4-month changes in end-diastolic volume indexes (r = 0.6; p = 0.04). Thus, elective revascularization of occluded coronary arteries with viable myocardium after myocardial infarction improves left ventricular function and lessens remodeling if the artery remains patent during follow-up.

Value of rescue percutaneous transluminal coronary angioplasty following unsuccessful thrombolytic therapy in patients with acute myocardial infarction. Thrombolysis in Myocardial Infarction Investigators

Rescue percutaneous transluminal coronary angioplasty (PTCA) has been advocated as a mechanical method to achieve reperfusion in instances where the myocardial infarct artery remains occluded after thrombolytic therapy. Most prior reports of rescue PTCA have been observational and analyses of value have been inconclusive. To evaluate the benefit of rescue PTCA, we studied 133 patients enrolled in the Thrombolysis in Myocardial Infarction Phase I Open Label and Phase II trials who had an occluded infarct-related artery after thrombolytic therapy. According to protocol, 100 consecutive patients had no rescue PTCA performed (no rescue group), and 33 consecutive patients underwent protocol-directed rescue PTCA (rescue group). The 2 cohorts were compared for clinical and angiographic outcome. Baseline characteristics of the 2 groups were similar. Rescue PTCA was attempted in each rescue group patient and was successful in 82%. At 21 days the mortality rate was 12% in the rescue group and 7% in the no rescue group (p = NS). Failed rescue PTCA was associated with a mortality of 33%. Reinfarction occurred in 6% of patients in the rescue group, and in 5% of those in the no rescue group (p = NS). At 21 days, mean left ventricular ejection fraction was 51 +/- 13% in the rescue group and 48 +/- 12% in the no rescue group (p = NS). We conclude that the routine use of rescue PTCA does not appear to offer significant benefit beyond that of contemporary medical therapy after thrombolytic failure.

Coronary artery bypass graft surgery after thrombolytic therapy in the Thrombolysis in Myocardial Infarction Trial, Phase II (TIMI II)

OBJECTIVES

We examined the results of coronary artery bypass graft surgery after thrombolytic therapy in the Thrombolysis in Myocardial Infarction trial, Phase II (TIMI II) with particular emphasis on patient characteristics, the impact of antecedent percutaneous transluminal coronary angioplasty and morbidity and mortality in certain subgroups.

BACKGROUND

Coronary bypass surgery is frequently used after thrombolytic therapy, but there is relatively little information with regard to early and late outcomes.

METHODS

We analyzed 3,339 patients enrolled in the TIMI II trial. Bypass surgery was performed in 390 patients (11.7%): 54 (14%) within 24 h after entry into the trial or within 24 h of coronary angioplasty and 336 (86%) between 24 h and 42 days after entry.

RESULTS

Perioperative mortality rates were, respectively, 16.7% and 3.9% (p < 0.001); perioperative myocardial infarction rates were 5.6% and 6.2%, respectively; and major hemorrhagic events occurred in 74% and 50.9%, respectively (p = 0.002). On multivariate analysis, the only independent predictor of perioperative mortality was bypass surgery within 24 h after entry or after coronary angioplasty. Among patients undergoing bypass surgery within 24 h of entry or after coronary angioplasty, the prevalence of multivessel disease (59.1% vs. 77.8%) and use of the internal thoracic artery (18.5% vs. 62.5%) were lower than in the remaining surgical patients. Among the 322 perioperative survivors, the 1-year mortality rate after discharge was only 2.2% and 1.9%, respectively, in the two groups. Only one patient had a documented recurrent myocardial infarction during the first year.

CONCLUSIONS

The increased mortality rate with bypass surgery after thrombolytic therapy, particularly in patients undergoing operation within 24 h of coronary angioplasty or during the involving phase of infarction, must be balanced against the excellent 1-year prognosis and perioperative survivors, who are in general a group at higher risk of death or recurrent infarction. These data provide a basis for comparison for future studies.

Risk stratification for long-term outcome after elective coronary angioplasty: a multivariate analysis of 5,000 patients

OBJECTIVES

We attempted to develop a statistical model to facilitate risk stratification for long-term outcome after elective coronary angioplasty.

BACKGROUND

Our understanding of factors related to long-term outcome after coronary angioplasty is limited. Adequate assessment of risk indexes could potentially lead to more appropriate use of percutaneous revascularization.

METHODS

We studied 5,000 consecutive patients and assessed 19 clinical and anatomic variables as predictors of long-term event-free survival. Events were defined as death of any cause, myocardial infarction, bypass surgery or repeat percutaneous transluminal coronary angioplasty. Cox proportional hazards models were used to develop an equation for predicting event-free survival in a subset of 4,000 patients. The equation was validated with the remaining 1,000 patients. Variables that were significantly associated with an adverse outcome in the multivariate model included age > 60 years, extent of disease, Canadian Cardiovascular Society functional class, previous coronary angioplasty, male gender, history of diabetes mellitus, history of hypertension and history of congestive heart failure.

RESULTS

The statistical model was used to develop a simplified scoring system, and the patients were assigned to three risk subgroups. Event-free survival curves for the three groups were significantly different (p = 0.0001). High risk patients had worse outcomes for each of the end points compared with low and moderate risk patients (p < 0.02).

CONCLUSIONS

We demonstrated that clinical and anatomic variables can be used to risk-stratify long-term outcome after angioplasty, that a simplified scoring system can be used for risk stratification and that high risk patients have a low event-free survival.

Coronary angioplasty in the patient with acute myocardial infarction

In patients with acute myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA) may be used (1) to restore antegrade flow in the infarct artery (so called "primary" PTCA) instead of thrombolytic therapy, (2) to establish antegrade coronary flow after unsuccessful thrombolytic therapy (so called "rescue" or "salvage" PTCA), and (3) to reduce the residual infarct artery stenosis after successful thrombolysis. This review examines the prospective, randomized studies that have addressed the use of PTCA for each of these purposes. In selected circumstances, PTCA is a reasonable alternative to thrombolytic therapy in patients with evolving or recent Q-wave myocardial infarction. In those patients with acute myocardial infarction complicated by cardiogenic shock, PTCA may be the preferred treatment. After thrombolytic therapy, the use of PTCA in the absence of spontaneous or provocable ischemia offers no benefit with regard to left ventricular function or survival. In this circumstance, its use is associated with an excessive risk of bleeding, transfusions, and emergent coronary artery bypass surgery when performed within hours of infarction.

Assessing prognosis after acute myocardial infarction in the thrombolytic era

The use of physiologic testing for prognostication continues to be useful and widely applied in the predischarge evaluation of patients recovering from an uncomplicated acute myocardial infarction in the thrombolytic era. Because patients with abnormal exercise test results are now routinely sent for angiography, there are no randomized trials or experimental confirmation that exercise parameters are still associated with the same prognostic value in the thrombolytic era. Nevertheless, the excellent outcomes in patients treated with thrombolytic therapy and risk stratified with exercise testing provide strong empiric support for the continued use of noninvasive testing of patients without complications after thrombolytic therapy. Reviews of patient cohorts enrolled in trials of thrombolytic therapy show that these patients have a lower incidence of multivessel disease and less evidence of ischemia (ST segment depression or thallium 201 redistribution) compared with prethrombolytic cohorts. For this and other reasons, the sensitivity and specificity of exercise variables for prognosis or detection of multivessel disease are not as strong. The addition of perfusion imaging will enhance the sensitivity for detection of ischemia within or remote from the infarct zone and will provide information regarding viability. Patients who are unable to exercise or those with poor exercise tolerance, an abnormal exercise blood pressure response, inducible ischemia, or nonsustained ventricular tachycardia are candidates for further invasive evaluation and consideration for coronary revascularization. With 201Tl imaging, evidence for increased pulmonary uptake of the tracer is indicative of high risk and a high probability of an adverse outcome with medical therapy. Low-risk patients are those who achieve their target heart rate or work load without inducible angina, ST segment depression, reversible perfusion abnormalities, or increased lung 201Tl uptake. Defect size is reflective of infarct size, and patients with extensive areas of nonreversible hypoperfusion are also at high risk for future events even in the absence of ischemia. Finally, pharmacologic stress imaging with dipyridamole, adenosine, or dobutamine has been found to be safe when employed for stress testing soon after uncomplicated infarction.

Effects on the signal-averaged electrocardiogram of opening the coronary artery by thrombolytic therapy or percutaneous transluminal coronary angioplasty during acute myocardial infarction

One hundred twenty-nine patients were retrospectively analyzed and divided into 3 groups according to (1) the presence of a patent artery obtained either spontaneously or after thrombolytic therapy but without percutaneous transluminal coronary angioplasty (PTCA) (group I, n = 83), (2) the presence of a patent artery after opening by PTCA (group II, n = 29), or (3) absence of reperfusion despite thrombolytic therapy or PTCA (group III, n = 17). Thrombolytic therapy was given within 4 hours after onset of symptoms (mean 2.5 +/- 1.0 hours) and PTCA was performed within 24 hours after the onset of symptoms (mean 6 +/- 6 hours). Signal averaging was performed within 24 hours after cardiac catheterization. An abnormal signal-averaged electrocardiogram was present in 10 of 83 (12%) group I, 9 of 29 (31%) group II and 7 of 17 (41%) group III patients (p < 0.05 group I vs II, p < 0.01 group I vs III, no statistical difference group II vs III). Therefore, in contrast to reperfusion by thrombolytic therapy the incidence of abnormalities on the signal-averaged electrocardiogram early after myocardial infarction is not reduced by an early opening of the culprit vessel by PTCA.