PowerPoint slides on Clinical
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AHA 2002 Metting Coverage
ASSENT
III Plus: Assessment of the Safety and Efficacy of New Thrombolytic Regimens III
Plus
Prehospital administration of thrombolysis in acute MI is safe, effective,
and reduces time-to-treatment, and thrombolysis with tenecteplase plus
enoxaparin reduces in-hospital ischemic events, although at some increased risk
of bleeding and ICH, particularly in elderly women.
CARDINAL:
Complement and Reduction of Infarct Size After Angioplasty or Lytics
The CARDINAL study (COMPLY and COMMA) found no significant difference in
infarct size between patients randomized to pexelizumab or placebo. However, the
mortality rate was significantly decreased among AMI patients treated with the
drug and PCI.
Emergency
PCI safe and effective without surgical backup
with slide / New data from the National Registry of Myocardial
Infarction show that performing emergency PCI in hospitals without on-site
cardiac surgery is safe and effective. In fact, the results suggest the
"little guys" are doing better than the big hospitals.
American Heart
Association Scientific Sessions 2002.
[ Nov 17, 2002 ]
TETAMI:
Treatment of Enoxaparin and Tirofiban in Acute Myocardial Infarction
The use of enoxaparin or tirofiban does not affect clinical outcomes of
STEMI patients who are ineligible for reperfusion.
Clinical
Implications of Post-PCI Sustained Hypotension in the Acute Myocardial
Infarction Setting
A pooled analysis of the PAMI trial results reveals that sustained
hypotension following intervention causes a higher risk of MACE and mortality.
INTEGRITI
Substudy: Combination Therapy With GP IIb/IIIa Inhibition and Thrombolytic
Therapy in STEMI Patients
Combination therapy with eptifibatide and TNK is associated with an improved
"blush score" in STEMI patients.
Prognostic
Implications of Left Ventricular Remodeling Patterns Following Mechanical
Reperfusion
Study finds that left ventricular remodeling can be predicted by clinical
and echocardiographic variables and is associated with poor long-term outcomes.
Predicting
Outcomes in STEMI Patients Following PCI in the Age of Modernized Techniques
New data from the American College of Cardiology-National Cardiovascular
Data Registry reveal that age, gender, multivessel disease, and location of
infarct are predictors of MACE in STEMI patients following PCI.
Beta-Blocker
vs Calcium Antagonist Therapy in Japanese AMI Patients
Calcium antagonists may be more useful than beta-blockers in Japanese AMI
patients, possibly by preventing heart failure.
TCT 2002 Abstracts
TCT 2002 Meeting Coverage
| The PRAGUE-2 Trial | P. Widimsky |
| ACE Trial | D. Antoniucci |
PRAGUE-2:
Comparison of PCI to Thrombolysis for the Treatment of AMI
As presented at the ESC, and subsequently at TCT, the PRAGUE-2 trial found
that transportation from a primary center to an interventional facility for PCI
intervention is more effective in improving outcomes in AMI patients vs
thrombolytic therapy.
TCT 2002 Expert Presentations
Coronary State of the Art
ACE:
Abciximab cuts 30-day event rate after MI intervention with carbon-coated stent
with slides / Using abciximab in MI intervention with a carbon-coated
stent significantly cut the 1-month rate of clinical events in a randomized
study. The ACE trial's broad patient population was said to reflect the real
world more than did those of prior trials of abciximab in the same clinical
setting.
Transcatheter Cardiovascular Therapeutics 2002. [ Sep 30, 2002 ]
ESC 2002 Meeting Coverage
In-Depth
Late-Breaking Clinical Trials I: GRACIA, PRAGUE-2, MAGIC, GIPS, RITA-3
Luis Gruberg, MD
In-Depth
Late-Breaking Clinical Trials II: BEST, PRAGUE-4, Euro-SPAH, OPTIMAAL, ACE
Luis Gruberg, MD
GRACIA:
Early intervention may be superior to medical therapy in AMI
with slides / Combined pharmacological and interventional therapy in
AMI patients reduces hospital stay and cardiac events after discharge and does
not increase adverse events at 30 days, the GRACIA trial shows.
European
Society of Cardiology Congress 2002 [ Sep 02, 2002 ]
Transfer
for PCI again shown better than local thrombolysis for MI patients: PRAGUE-2
with slides / The PRAGUE-2 results mirror those of the DANAMI-2 and
Air-PAMI studies, reported earlier this year, and a widespread change of
strategy is now justified, the lead investigator says.
European Society of
Cardiology Congress 2002. [ Sep 01, 2002 ]
DANAMI-2:
Intermediate results confirm benefit of transfer for primary PCI over
thrombolytics for MI
with slides / Intermediate results of the DANAMI-2 trial, comparing
thrombolysis to referral for primary PCI for patients with ST-elevation MI,
continue to support an advantage for the transfer strategy in the reduction of
the composite endpoint of death, reinfarction, or stroke.
XIVth World Congress
of Cardiology. [ May 08, 2002 ]
ACC 2002 Meeting Coverage
| Adenosine to Reduce Infarct Size and Assist In Reperfusion Therapy - Results of AMISTAD II | A. M. Ross |
| DANAMI-2 Supports Primary PTCA Even With 3 Hours Transport Time | H. R. Andersen |
AMISTAD
II: Adenosine promising in reperfusion injury
Giving adenosine looks like a promising approach to reducing reperfusion
injury in patients with anterior MI, according to results of the Acute
Myocardial Infarction Study of Adenosine II trial. Although the overall analysis
did not show significant improvements with adenosine versus placebo, the
higher-dose group did show a significant reduction in infarct size and a
stronger trend in event reduction.
American College of Cardiology 51st Annual
Scientific Session. [ Mar 17, 2002 ]
DANAMI-2:
even with 3 hours of hospital transfer time, AMI patients still fare better with
PCI
Patients reporting to hospital with acute ST-elevation MI are better off
being transferred to a center that performs PTCA rather than receiving lytic
therapy at their local hospital, even if the transfer takes up to 3 hours,
according to DANAMI-2 trial investigators.
American College of Cardiology 51st
Annual Scientific Session. [ Mar 20, 2002 ]
Summaries of important articles from major peer-reviewed journals
Primary angioplasty versus intravenous
thrombolytic therapy for acute myocardial infarction: a quantitative review of
23 randomised trials
Keeley EC, et al.
Lancet 2003;361:13-20
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12517460
Primary PTCA was better than thrombolytic therapy at reducing overall short-term
death (7% [n=270] vs 9% [360]; p=0.0002), death excluding the SHOCK trial data
(5% [199] vs 7% [276]; p=0.0003), non-fatal reinfarction (3% [80] vs 7% [222];
p<0.0001), stroke (1% [30] vs 2% [64]; p=0.0004), and the combined endpoint
of death, non-fatal reinfarction, and stroke (8% [253] vs 14% [442];
p<0.0001). The results seen with primary PTCA remained better than those seen
with thrombolytic therapy during long-term follow-up, and were independent of
both the type of thrombolytic agent used, and whether or not the patient was
transferred for primary PTCA.
Interpretation: Primary PTCA is more effective than thrombolytic therapy
for the treatment of ST-segment elevation AMI.
GUSTO-V
published: Is there now a role for the reteplase-abciximab combination?
Lincoff AM et al.
JAMA 2002; 288: 2130-2135.[ Nov 05, 2002 ]
Although there is no improvement in mortality at 1 year with the combination
of abciximab and half-dose reteplase over full-dose reteplase alone, the GUSTO-V
investigators say there may still be a role for the combination in certain
patients and as a bridge to angioplasty.
Primary
angioplasty "no better" than prehospital fibrinolysis: CAPTIM
Bonnefoy E et al.
Lancet 2002; 360:825-829. [ Sep 13, 2002 ]
Updated with interview / with slide / In a finding that would
appear to go against the swelling tide of support for primary angioplasty in
acute MI, results of a study comparing primary angioplasty with prehospital
administration of alteplase with rescue angioplasty concludes one strategy is no
better than the other. The study's power to detect a difference, though, is at
issue.
Abciximab
use in primary stenting debated
Herrmann HC.
New Engl J Med 2002; 247: 367;
Stone GW et
al.
New Engl J Med 2002; 247: 367-368. [ Jul 31, 2002 ]
Whether to use abciximab in MI patients receiving stents on the basis of the
CADILLAC trial is the subject of correspondence in New England
Journal of Medicine.
Prehospital
reteplase speeds time to treatment for STEMI: ER-TIMI 19
Morrow
DA et al.
J Am Coll Cardiol 2002;40:71-77. [ Jul 02, 2002 ]
It's not only feasible, it also saves valuable time, even in the context of
today's improved transport and door-to-drug times, according to the Early
Retavase-Thrombolysis In Myocardial Infarction (ER-TIMI) 19 investigators.
"One
of the biggest debates in modern cardiology": PCI vs thrombolysis for acute
MI
Grines C et al; de Boer M-J et al.
J Am
Coll Cardiol 2002; 39: 1713-9; 1723-8. [ Jun 04, 2002 ]
with slide / Factor in issues such as patient age, hospital transfer,
and access to surgical back-up, and selecting PTCA or thrombolysis becomes what
some experts call "one of the biggest debates in modern cardiology."
Two studies, including the results of the Air-PAMI trial, add new
information and raise new questions.
PCI
bests thrombolysis at centers with no onsite surgical back-up: C-PORT trial
Aversano T et al, Cannon C.
JAMA 2002; 287: 1943-51, 1987-9. [ Apr 16, 2002 ]
Geography, weather, and luck should not determine whether patients with acute
MI get primary angioplasty or thrombolysis, researchers say. Reviewing the newly
published C-PORT trial in light of DANAMI-2 and other trials, experts agree that
the time has come to rethink the status quo in terms of how and where AMI
patients are treated.
CADILLAC
published: stenting superior to primary PTCA alone
Stone GW et al.
N Engl J Med 2002; 346:957-66. [ Mar 27, 2002 ]
Results of the CADILLAC trial, showing stents to be superior to primary PTCA
in acute MI (AMI) patients, with or without adjunctive abciximab, have now been
published. Improvements in stent design, operator technique, and use of
adjunctive pharmacotherapy likely account for the improved outcomes in CADILLAC
compared to previous stent/PTCA trials.
Aqueous
oxygen delivery after primary angioplasty safe, feasible
Dixon SR, et al.
J Am Coll Cardiol 2002;39:387-92. [ Mar 01, 2002 ]
Researchers are investigating whether delivery of aqueous oxygen to ischemic
tissues after primary angioplasty may improve outcomes for patients suffering
myocardial infarction. Results of a pilot study suggest the approach is safe and
feasible, and a phase II trial, recently approved by the FDA, is already
underway.
Early
revascularization after MI linked to substantial reduction in 1-year mortality
Stenestrand U
& Wallentin L.
Lancet 2002; 359: 1805-11. [ May 23, 2002 ]
with slide / A prospective study of Swedish registry data has found
that early revascularization in patients with acute MI is associated with a
substantial reduction in 1-year mortality. The finding lends support to the use
of early interventions in this setting, the investigators say.
Full text journal article Sep 2002
Integrating GP IIb/IIIa
Inhibition into Treatment Strategies for Acute ST-Elevation Myocardial
Infarction
Against the background of established clinical benefit in non-ST segment
elevation acute coronary syndromes (ACS) and elective percutaneous
revascularization, recent trials examining the role of glycoprotein (GP) IIb/IIIa
inhibition in acute myocardial infarction (AMI) have been based on the rationale
that effective platelet inhibition is fundamental to reperfusion strategies
designed to restore myocardial perfusion, limit infarct size, and improve
survival.
Full text journal article Sep 2002
How Long Is Too Long?
Association of Time Delay to Successful Reperfusion and Ventricular Function
Outcome in Acute Myocardial Infarction: The Case for Thrombolytic Therapy Before
Planned Angioplasty for Acute Myocardial Infarction
The purpose of this study was to quantify the effect of time
delays to reperfusion on ventricular function after myocardial infarction.
Background: Direct angioplasty for myocardial infarction is associated with a
high rate of successful reperfusion compared with pharmacologic reperfusion.
Conclusions: Delay in time to reperfusion, measured in minutes, results in
significant loss of ventricular function after myocardial infarction.
Full text journal article Jun 2002
Myocardial Infarction
and the Culprit Plaque: Myths, Data and Statistics
Should therapy that targets both local and systemic effects or a directed
local approach be utilized to reduce ACS?
Integrated Analysis of Myocardial Blush and
ST-segment Elevation Recovery After Successful Primary Angioplasty: Real-time
Grading of Microvascular Reperfusion and Prediction of Early and Late Recovery
of Left Ventricular Function
Poli A, Fetiveau R, Vandoni P, et al.
Circulation. 2002;106(3):313-318
http://www.medscape.com/viewarticle/440839
Myocardial blush score and ST-segment resolution are 2 very simple tools
that provide invaluable information on the viability of myocardial function.
They also have profound prognostic implications in the aftermath of primary
angioplasty during acute myocardial infarction. The main drawback of this study
and of all previous studies based on myocardial blush score is the subjectivity
of the test. Furthermore, not all physicians perform the necessary shots in the
right angles and for the necessary length of time to be able to adequately
assess the blush score. The small sample size was also a limitation.
Review
THROMBOLYSIS FOR ACUTE MYOCARDIAL INFARCTION: DRUG REVIEW
Does thrombolysis after AMI improve survival rates? A review of data from
The National Registry of Myocardial Infarction.
MedGenMed, January 2, 2002
http://cardiology.medscape.com/46730.rhtml?srcmp=card-010402
Editorial
Expanding the reach of primary percutaneous
coronary intervention for the treatment of acute myocardial infarction
Cannon CP, et al.
J Am Coll Cardiol 2002;39:1720-2.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12039481
Effect of treatment delay on outcomes in
patients with acute myocardial infarction transferred from community hospitals
for primary percutaneous coronary intervention
Brodie BR, et al.
Am J Cardiol 2002;89:1243-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12031721
Patients transferred from community hospitals for primary percutaneous coronary
intervention have almost 1-hour additional treatment delay, but this does not
appear to have a major adverse effect on clinical outcomes. These data should
encourage further randomized trials to evaluate the role of transfer for
mechanical reperfusion in patients presenting to community hospitals with acute
myocardial infarction
Early experience with a helical coronary
thrombectomy device in patients with acute coronary thrombosis
Constantinides S, et al.
Heart 2002;87:455-60.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11997421
http://heart.bmjjournals.com/cgi/content/full/87/5/455
http://heart.bmjjournals.com/cgi/content/abstract/87/5/455
Thrombectomy with the X-SIZER catheter system appears promising in percutaneous
coronary intervention where thrombus extraction is considered necessary before
stent implantation.
Relationship of the TIMI myocardial
perfusion grades, flow grades, frame count, and percutaneous coronary
intervention to long-term outcomes after thrombolytic administration in acute
myocardial infarction
Gibson CM, et al.
Circulation 2002;105:1909-13.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11997276
http://www.circulationaha.org/cgi/content/full/105/16/1909
http://www.circulationaha.org/cgi/content/abstract/105/16/1909
Both improved epicardial flow (TFG 2/3 and low CTFCs) and tissue-level perfusion
(TMPG 2/3) at 90 minutes after thrombolytic administration are independently
associated with improved 2-year survival, suggesting complementary mechanisms of
improved long-term survival. Although rescue PCI reduced long-term mortality,
improved microvascular perfusion (TMPG 2/3) before PCI was also related to
improved mortality independently of epicardial blood flow and the performance of
rescue or adjunctive PCI. Further prospective trials are warranted to re-examine
the benefit of early PCI with thrombolysis.
Facilitated percutaneous intervention
following combination therapy with reteplase and abciximab for acute myocardial
infarction
Weinstock BS.
J Invasive Cardiol 2002;14:100-4; quiz 104-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11818648
Long-term mortality benefit with the
combination of stents and abciximab for cardiogenic shock complicating acute
myocardial infarction
Chan AW, et al.
Am J Cardiol 2002;89:132-6.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11792330
Treatment with the combination of stent and abciximab resulted in higher
procedural Thrombolysis In Myocardial Infarction 3 flow rates and a long-term
mortality benefit in patients with cardiogenic shock complicating acute
myocardial infarction.
Relation between preintervention
angiographic evidence of coronary collateral circulation and clinical and
angiographic outcomes after primary angioplasty or stenting for acute myocardial
infarction
Antoniucci D, et al.
Am J Cardiol 2002;89:121-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11792328
By multivariate analysis,
Collateral circulation (CC) did not emerge as a significant variable in relation
to 6- month clinical and angiographic outcomes. CC does not exert a protective
effect in patients who undergo mechanical intervention in the first 6 hours of
AMI onset.
Sex-based analysis of outcome in patients
with acute myocardial infarction treated predominantly with percutaneous
coronary intervention
Mehilli J, et al.
Jama 2002;287:210-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11779263
Despite their more advanced age and greater prevalence of diabetes or
hypertension, women with AMI who were treated with a reperfusion strategy
largely based on percutaneous coronary interventions show a similar outcome as
men.
Development of a risk adjustment mortality
model using the American College of Cardiology-National Cardiovascular Data
Registry (ACC-NCDR) experience: 1998-2000
Shaw RE, et al.
J Am Coll Cardiol 2002;39:1104-12.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11923032
A risk adjustment model for in-hospital mortality after PCI was successfully
developed using a contemporary multi-center registry. This model is an important
tool for valid comparison of in-hospital mortality after PCI.
Gender differences in acute myocardial
infarction in the era of reperfusion (the MITRA registry)
Heer T, et al.
Am J Cardiol 2002;89:511-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11867033
Women with STEMI receive reperfusion therapy less often than men. They
experience recurrent angina and congestive heart failure more often during their
hospital stay. The age-adjusted long-term mortality is not different between men
and women, but there is a trend for a higher short-term mortality in women
Impact of normalized myocardial perfusion
after successful angioplasty in acute myocardial infarction
Stone GW, et al.
J Am Coll Cardiol 2002;39:591-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11849856
Abnormal myocardial perfusion is present in most patients following primary or
rescue PCI in AMI, despite restoration of brisk epicardial coronary flow. In
high risk patients achieving TIMI-3 flow after intervention, the myocardial
blush score may be used to stratify prognosis into excellent, intermediate and
poor survival. Further study is warranted to examine whether adjunctive
mechanical or pharmacologic strategies can further improve myocardial perfusion
and survival of patients with acute myocardial infarction undergoing
intervention.
Initial experience with hyperoxemic
reperfusion after primary angioplasty for acute myocardial infarction: results
of a pilot study utilizing intracoronary aqueous oxygen therapy
Dixon SR, et al.
J Am Coll Cardiol 2002;39:387-92.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11823074
Intracoronary hyperoxemic reperfusion is safe and well tolerated after primary
PTCA. These preliminary data support the need for a randomized controlled trial
to determine if hyperoxemic reperfusion enhances myocardial salvage or improves
long-term outcome
Percutaneous reperfusion of left main
coronary disease complicated by acute myocardial infarction
Neri R, et al.
Catheter Cardiovasc Interv 2002;56:31-4.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11979530
A percutaneous mechanical intervention strategy in patients with left main
disease complicated by AMI is feasible and effective, and patients discharged
alive have a good mid-term prognosis.
Rheolytic thrombectomy with Angiojet in
thrombus-containing lesions
Singh M, et al.
Catheter Cardiovasc Interv 2002;56:1-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11979522
High procedural success can be achieved with the AngioJet thrombectomy device in
lesions containing thrombus. It is effective in both native coronary arteries
and vein graft interventions. However, the long-term outcome of patients with
vein graft intervention was worse.
Thrombolytic therapy vs primary percutaneous
coronary intervention for myocardial infarction in patients presenting to
hospitals without on- site cardiac surgery: a randomized controlled trial
Aversano T, et al.
Jama 2002;287:1943-51.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11960536
Compared with thrombolytic therapy, treatment of patients with primary PCI at
hospitals without on-site cardiac surgery is associated with better clinical
outcomes for 6 months after index MI and a shorter hospital stay.
Early resolution of ST-segment elevation
correlates with myocardial salvage assessed by Tc-99m sestamibi scintigraphy in
patients with acute myocardial infarction after mechanical or thrombolytic
reperfusion therapy
Dong J, et al.
Circulation 2002;105:2946-9.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12081985
http://www.circulationaha.org/cgi/content/full/105/25/2946
http://www.circulationaha.org/cgi/content/abstract/105/25/2946
Early resolution of ST-segment elevation in surface ECG correlates with
myocardial salvage as assessed by scintigraphy in patients with AMI after
reperfusion therapy. These data provide an explanation for the favorable
prognostic value of the ST- segment resolution and support the use of this
parameter to compare the efficacy of different reperfusion strategies.
Effects of hospital volume on long-term
outcomes after percutaneous transluminal coronary angioplasty after acute
myocardial infarction
Doucet M, et al.
Am Heart J 2002;144:144-50.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12094201
http://www.mosby.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=a123571&target=
Overall adverse event rates at 6 months after PTCA do not differ between
hospital volume groups. The higher rate of CABG in low-volume hospitals and the
higher rate of repeat PTCA in high-volume hospitals may represent different
physician preferences for the treatment of failed PTCA rather than higher
complication rates.
Correlates of coronary blood flow before and
after percutaneous coronary intervention and their relationship to angiographic
and clinical outcomes in the RESTORE trial
Gibson CM, et al.
Am Heart J 2002;144:130-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12094199
http://www.mosby.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=a123142&target=
In addition to MLD, variables such as the presence of thrombus, left coronary
artery lesion location, and dissection grade are associated with slower coronary
blood flow after PTCA. In turn, post-PTCA CTFCs were an independent predictor of
late lumen loss and follow-up MLDs. Furthermore, patients who die or who sustain
other adverse cardiac events have slower coronary blood flow and greater
thrombus burden after PTCA
Prognosis after acute myocardial infarction
continues to improve in the reperfusion era in the community of Goteborg
Herlitz J, et al.
Am Heart J 2002;144:89-94.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12094193
http://www.mosby.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=a123312&target=
For consecutive patients aged <75 years who were hospitalized for AMI in the
community of Goteborg, the Authors found that in the thrombolytic era, major
changes in medical and nonmedical treatment still took place associated with a
continuing decrease in mortality rates during 3 years of follow-up. A similar
reduction of CHD mortality rates was seen in the same age group within the
community of Goteborg.
Incidence and clinical significance of
distal embolization during primary angioplasty for acute myocardial infarction
Henriques JP, et al.
Eur Heart J 2002;23:1112-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12090749
Distal embolization in patients treated with primary angioplasty is visible on
the coronary angiogram in 15.2% of patients. It is related to reduced myocardial
reperfusion, more extensive myocardial damage and a poor prognosis. Additional
pharmacological interventions and/ or mechanical devices should be studied to
prevent and/or treat distal embolization.
Rationale for on-site cardiac surgery for
primary angioplasty: a time for reappraisal
Singh M, et al.
J Am Coll Cardiol 2002;39:1881-9.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12084584
This review article focuses on the need for on-site cardiac surgery in patients
with acute myocardial infarction undergoing primary angioplasty at centers
without on-site cardiac surgical backup. It gives an overview of the need for
emergency bypass surgery in both the large trial setting and the community
hospital setting. Special consideration is also given to the risks and benefits
of primary angioplasty compared with thrombolytic therapy, transfer to an
institution with an on-site cardiac surgical facility compared with primary PCI,
the frequency and indications for emergency cardiac surgery related and
unrelated to primary angioplasty and the requirements for primary angioplasty
that must be met in hospitals without the capability of on-site cardiac surgery.
Time course and relation to local viability
of microvascular function and volume after reperfused acute myocardial
infarction
Garot P, et al.
Am J Cardiol 2002;89:1341-6.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12062725
The presence of reversible microvascular dysfunction at the early stage after
acute myocardial infarction is associated with local tissue viability in humans.
Predictors of door-to-balloon delay in
primary angioplasty
Angeja BG, et al.
Am J Cardiol 2002;89:1156-61.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12008167
The strongest independent predictor of delay was hospital transfer, along with
non-daytime presentation and low-volume centers. Older age, female sex, and
non-white race were weaker predictors. Both patient and hospital factors are
associated with delay in pPTCA after presentation. These findings may help
design treatment algorithms to minimize delay, thus improving the survival
benefit of pPTCA. These results may also help design trials of combination
reperfusion strategies.
Comparison of angioplasty with stenting,
with or without abciximab, in acute myocardial infarction
Stone GW, et al.
N Engl J Med 2002;346:957-66.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11919304
http://content.nejm.org/cgi/content/full/346/13/957
http://content.nejm.org/cgi/content/abstract/346/13/957
At experienced centers, stent implantation (with or without abciximab therapy)
should be considered the routine reperfusion strategy.
Practice variation and missed opportunities
for reperfusion in ST- segment-elevation myocardial infarction: findings from
the Global Registry of Acute Coronary Events (GRACE)
Eagle KA, et al.
Lancet 2002;359:373-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11844506
A substantial proportion of patients who are eligible for reperfusion therapy
still do not receive this treatment. These typically high-risk patients can be
identified in advance, and reasons for the underuse of these beneficial
treatments need to be clarified.
Myocardial salvage after coronary stenting
plus abciximab versus fibrinolysis plus abciximab in patients with acute
myocardial infarction: a randomised trial
Kastrati A, et al.
Lancet 2002;359:920-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11918909
In patients with acute myocardial infarction, a reperfusion strategy based on
stenting with abciximab produced more myocardial salvage than the combination of
fibrinolysis plus abciximab. Larger studies are needed to assess whether these
effects translate into clinical benefit
Improving quality of care for acute
myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative
Mehta RH, et al.
Jama 2002;287:1269-76.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11886318
Implementation of guideline-based tools for AMI may facilitate quality
improvement among a variety of institutions, patients, and caregivers. This
initial project provides a foundation for future initiatives aimed at quality
improvement
Primary angioplasty and selection bias
inpatients presenting late (>12 h) after onset of chest pain and ST elevation
myocardial infarction
Elad Y, et al.
J Am Coll Cardiol 2002;39:826-33.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11869848
Patients receiving early invasive therapy had lower risk features on
presentation. Selection bias may play an important role in choosing these
patients' course of treatment and their subsequent outcomes. Certain patients
presenting with AMI and duration of chest pain >12 h may benefit from early
invasive therapy. These patients could be characterized in a randomized trial.
Primary angioplasty reduces the risk of left
ventricular free wall rupture compared with thrombolysis in patients with acute
myocardial infarction
Moreno R, et al.
J Am Coll Cardiol 2002;39:598-603.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11849857
In patients with AMI, primary angioplasty reduces the risk of free wall rupture
in comparison with thrombolysis.
A randomized comparison of direct stenting
with conventional stent implantation in selected patients with acute myocardial
infarction
Loubeyre C, et al.
J Am Coll Cardiol 2002;39:15-21.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11755281
In selected patients with AMI, direct stenting can be applied safely and
effectively. This strategy may result in a significant reduction of
microvascular injury, as suggested by improved ST-segment resolution after
reperfusion with major potential clinical consequences.