Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology

Optimizing the use of thrombolytics in ST-segment elevation myocardial infarction

The advent of thrombolytic therapy was a major advance in the treatment of ST-segment elevation myocardial infarction (STEMI). The administration of fibrinolytic reperfusion therapy can reduce mortality rates by as much as 30%, with the greatest benefit observed if therapy is administered soon after symptom onset. Outcomes with thrombolytic therapy are improved if there is adjunctive treatment with aspirin, clopidogrel and an anti-thrombin agent. Although there is evidence that primary percutaneous coronary intervention (PCI) is the most effective reperfusion strategy, the majority of hospitals still do not have PCI capabilities and, thus, thrombolytic therapy remains a cornerstone of treatment for STEMI. Trials of thrombolytic therapy have demonstrated that initial patency rates can approach 85%, but there is still a need for improvement of non-invasive markers that predict failure or re-occlusion of the infarct-related artery. Because of the overwhelming data demonstrating the importance of rapid reperfusion, current studies are examining the role of earlier treatment of patients with STEMI via pre-hospital administration and/or coordinated systems for rapid diagnosis, transfer and delivery of definitive care. Facilitated PCI, a strategy of thrombolytic therapy followed by immediate PCI, has not been shown to be beneficial and current studies are examining the optimal timing of coronary angiography after thrombolytic therapy.

Chronic nitrate therapy is associated with different presentation and evolution of acute coronary syndromes: insights from 52,693 patients in the Global Registry of Acute Coronary Events

AIMS

Brief episode(s) of ischaemia may increase cardiac tolerance to a subsequent major ischaemic insult ('preconditioning'). Nitrates can pharmacologically mimic ischaemic preconditioning in animals. In this study, we investigated whether antecedent nitrate therapy affords protection toward acute ischaemic events using data from the Global Registry of Acute Coronary Events.

METHODS AND RESULTS

The dataset comprised 52,693 patients from 123 centres in 14 countries: 42,138 (80%) were nitrate-naïve and 10,555 (20%) were on chronic nitrates at admission. In nitrate-naïve patients, admission diagnosis was ST-segment elevation myocardial infarction (STEMI) in 41%, whereas 59% presented with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). In contrast, only 18% nitrate users showed STEMI, whereas 82% presented with NSTE-ACS. Thus, among nitrate users clinical presentation was tilted toward NSTE-ACS by more than four-fold, STEMI occurring in less than one of five patients (P < 0.0001). After adjustment (age, sex, medical history, prior therapy, revascularization, previous angina), chronic nitrate use remained independent predictor of NSTE-ACS (OR 1.36; 95% CI 1.26-1.46; P < 0.0001). Furthermore, regardless of presentation, within both STEMI and NSTEMI populations, antecedent nitrate use was associated with significantly lower levels of CK-MB and troponin (P < 0.0001 for all).

CONCLUSION

In this large multinational registry, chronic nitrate use was associated with a shift away from STEMI in favour of NSTE-ACS and with less release of markers of cardiac necrosis. These findings suggest that in nitrate users acute coronary events may develop to a smaller extent. Randomized, placebo-controlled trials are warranted to establish whether nitrate therapy may pharmacologically precondition the heart toward ischaemic episodes.

Achieving routine sub 30 minute door-to-balloon times in a high volume 24/7 primary angioplasty center with autonomous ambulance diagnosis and immediate catheter laboratory access

BACKGROUND

In primary angioplasty (primary percutaneous coronary intervention [PPCI]) for acute myocardial infarction, institutional logistical delays can increase door-to-balloon times, resulting in increased mortality.

METHODS

We moved from a thrombolysis (TL) service to 24/7 PPCI for direct access and interhospital transfer in April 2004. Using autonomous ambulance diagnosis with open access to the myocardial infarction center catheter laboratory, we compared reperfusion times and clinical outcomes for the final 2 years of TL with the first 3 years of PPCI.

RESULTS

Comparison was made between TL (2002-2004, n = 185) and PPCI (2004-2007, n = 704); all times are medians in minutes (interquartile range): for TL, symptom to needle 153 (85-225), call to needle 58 (49-73), first professional contact (FPC) to needle 47 (39-63), door to needle 18 (12-30) (mortality: 7.6% at 30 days, 9.2% at 1 year); for interhospital transfer PPCI (n = 227), symptom to balloon 226 (175-350), call to balloon 135 (117-188), FPC to balloon 121 (102-166), first door-to-balloon 100 (80-142) (mortality: 7.0% at 30 days, 12.3% at 1 year); for direct-access PPCI (n = 477), symptom to balloon 142 (101-238), call to balloon 79 (70-93), FPC to balloon 69 (59-82), door to balloon 20 (16-29) (mortality: 4.6% at 30 days, 8.6% at 1 year). There was no difference between direct-access PPCI and TL times for symptom to needle/balloon. Direct-access PPCI was significantly quicker for the group than in-hospital thrombolysis for door to needle/balloon times due to the lack of any long wait patients (P < .001).

CONCLUSIONS

Interhospital transfer remains slow even with rapid institutional door-to-balloon times. With autonomous ambulance diagnosis and open access direct to the catheter laboratory, a median door-to-balloon time of <30 minutes day and night was achieved, and >95% of patients were reperfused within 1 hour.

Polyvascular atherosclerotic disease: recognizing the risks and managing the syndrome

BACKGROUND

Patients with an initial ischemic event secondary to atherosclerosis have an increased risk of suffering a recurrent event not only in the same vascular territory, but in other territories as well. Patients with polyvascular disease, or atherosclerotic disease in more than one vascular territory, have worse clinical outcomes than those with disease in a single vascular territory. This suggests that atherosclerosis should be treated as a systemic disease with appropriately aggressive secondary preventive measures in order to prevent recurrent events throughout the arterial tree.

OBJECTIVE

To discuss relevant findings for the management of patients with polyvascular disease and provide guidance to clinicians who may not be aware of how best to manage these patients.

METHODS

Relevant English-language articles published from 1950 through February 2009 were identified by searching the Cochrane, MEDLINE, and Ovid databases using the terms 'atherosclerosis,' 'atherothrombosis,' 'cerebrovascular disease,' 'coronary artery disease,' 'cross-risk,' 'management guidelines,' 'peripheral arterial disease,' 'polyvascular,' and 'secondary prevention' either singly or in combination.

FINDINGS AND CONCLUSIONS

According to limited data from patient registries, anywhere from 15% to 30% of patients with atherosclerosis present with disease in multiple vascular territories and experience significantly greater rates of adverse cardiovascular events. Despite these findings, a search of the literature reveals a lack of studies comprised of patients with polyvascular disease only and very few reports on the results of patients with polyvascular disease enrolled in existing secondary prevention studies. Although any conclusions are limited by this small number of studies, clinicians typically treat only the initially affected territory without consideration of the other affected territories and may lack awareness of the overall atherothrombotic syndrome. In the future, clinical trials focused specifically on patients with polyvascular disease should be conducted in order to increase our knowledge on how to manage these patients. Evidence-based clinical practice guidelines are also necessary to improve the management of patients with polyvascular disease.

Prognostic significance and magnetic resonance imaging findings in aborted myocardial infarction after primary angioplasty

BACKGROUND

Aborted myocardial infarction (MI) is defined by major (> or =50%) ST-segment resolution and a lack of subsequent cardiac enzyme rise > or =2 the upper normal limit. This ultimate myocardial salvage has been observed in approximately 15% of ST-elevation MI (STEMI) patients after fibrinolysis. So far, the prognostic significance and magnetic resonance imaging (MRI) findings of an aborted MI after primary angioplasty have not been evaluated appropriately.

METHODS

We examined 420 consecutive STEMI patients undergoing primary angioplasty within 12 hours after symptom onset. All patients underwent MRI within 1 to 4 days. Clinical end points were major adverse cardiovascular events within 6 months after the index event.

RESULTS

Of the 420 STEMI patients, 58 (14%) fulfilled aborted MI criteria. As compared with true MI, patients with aborted MI had a significant lower infarct size, shorter pain-to-balloon time, and better left ventricular ejection fraction (P < .001, respectively). Aborted MI patients had a 6-month major adverse cardiovascular event rate of 1.7% versus 19.6% of true MI patients (P = .001). In aborted MI patients, MRI detected no myocardial scar in 30 (56%), and a minor necrosis/scar formation in 24 patients (44%).

CONCLUSION

The proven prognostic relevance of aborted MI makes it a meaningful end point and therapeutic target in future MI studies. MRI can further distinguish between true aborted MI with absence of myocardial scar and aborted MI with scar formations.

Effect of coronary collaterals on microvascular obstruction as assessed by magnetic resonance imaging in patients with acute ST-elevation myocardial infarction treated by primary coronary intervention

The aim of this study was to determine whether angiographically visible collaterals before reperfusion are associated with beneficial effects on infarct size, microvascular obstruction, and left ventricular function as measured by magnetic resonance imaging (MRI) in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). We examined 235 patients with STEMI and symptoms <12 hours. All patients had Thrombolysis In Myocardial Infarction grade < or =1 flow before PCI. Collateral flow was graded according to Rentrop classification. Patients were divided in 2 groups; group A had absent or weak collateral flow and group B had significant flow. In 166 patients there was absent or weak collateral flow, whereas 69 had significant flow. Extent of microvascular obstruction was significantly smaller in group B at early MRI (3.3% vs 2.1% of left ventricle, p = 0.009). Infarct size measured by peak creatine kinase release showed smaller infarcts in group B (p = 0.02), whereas MRI infarct size showed a weak trend (p = 0.20). At 6 months, a strong trend toward a lower rate of death or nonfatal reinfarction could be seen in group B (4.5% vs 12.2%, p = 0.07). In conclusion, well-developed collaterals before reperfusion by PCI in patients with STEMI are associated with a protective effect on coronary microcirculation.

Management of ST-segment elevation myocardial infarction: Comparison of the updated guidelines from North America and Europe

The American College of Cardiology/American Heart Association and the European Society of Cardiology each recently published updated guidelines for management of patients with acute ST elevation myocardial infarction. In this article, we highlight the most important new recommendations, review their supporting data, and describe differences between the guidelines. Key aspects of these updates include detailed guidance regarding the selection of a reperfusion strategy and the incorporation of newer adjunctive antithrombotic agents. Both new guidelines suggest caution in the administration of intravenous beta-blockers, avoidance of nonsteroidal anti-inflammatory agents, and support a more aggressive approach to secondary risk factor management. The 2 guidelines have some nuanced differences as well as some recommendations that are unique to each guideline. They present different levels of support for the 4 available adjunctive parenteral anticoagulants, vary in their endorsement of routine elective coronary angiography after fibrinolysis, and cite different targets for low density lipoprotein long-term. Major unique recommendations include the American College of Cardiology/American Heart Assocaition's emphasis of a stepped approach to analgesia in patients with musculoskeletal pain beginning with acetaminophen or aspirin and a lower target international normalized ratio in patients receiving warfarin, aspirin, and clopidogrel. Meanwhile, unique recommendations in the European Society of Cardiology guidelines include measures to prevent/treat microvascular obstruction and reperfusion injury associated with percutaneous coronary intervention and greater emphasis on maintaining eugylcemia. As these guidelines represent an evidence based approach, health care providers should become familiar with the new data and the resultant updated recommendations to ensure optimal treatment of their patients with ST-elevation myocardial infarction.

Door-to-balloon delays before primary angioplasty in the Regional Acute Myocardial Infarction Registry of Brittany. An analysis of the Observatoire Régional Breton sur l'Infarctus du myocarde (ORBI)

BACKGROUND

Minimizing delays to coronary reperfusion is critical in the management of acute myocardial infarction (AMI).

AIMS

To determine delays in in-hospital management and factors associated with delays of over 45min.

METHODS

We analysed data from the Observatoire Régional Breton sur l'Infarctus, a registry of AMI patients admitted within 24h of symptom onset (July 2007 to December 2008) to an interventional cardiology centre in Brittany. Prehospital delay was defined as time between first responder arrival at the patient and patient arrival at an interventional cardiovascular centre. In-hospital delay was defined as time between admission to the interventional cardiovascular centre and first balloon inflation. Patients were grouped according to duration of in-hospital delay (>45 vs <or=45min). Predictors of short in-hospital delay (<or=45min) were examined by logistic regression analysis.

RESULTS

The analysis included 560 patients (mean age 60.7+/-13 years; 443 men). Median delay between symptom onset and call for medical assistance was 50min (mean 115+/-180). Two-thirds (n=371) of patients were admitted to hospital during working hours (08:00-20:00h); 383 (68%) patients were managed by emergency medical services before admission. In-hospital delay was less than or equal to 45min for 296 (53%) patients. The mean overall (pre- and in-hospital) delay was 140 (median 109) min. Direct admission to a catheterization laboratory and admission during working hours were independently correlated with short in-hospital delay (odds ratios 20.8 [p<0.001] and 2.37 [p=0.004], respectively).

CONCLUSIONS

In Brittany, median in-hospital delay before treatment of AMI by primary angioplasty was over 45min in 50% of patients. Overall, delays were longer than recommended, due to excessively long prehospital delays. Patient admission during working hours and direct admission to a catheterization laboratory were associated with short in-hospital delay.

[Acute non protected main left coronary artery occlusion: a report of six cases treated by angioplasty]

AIM

Acute main left coronary artery occlusion is rarely observed during primary angioplasty in myocardial infarction. This retrospective study reports the results of six patients treated by angioplasty in a hospital without cardiac surgery department.

PATIENTS AND METHODS

From 2002 to 2009, 746 patients were treated by primary angioplasty for acute coronary syndromes with ST elevation. Among those patients, six (0,7%) had acute non protected main left coronary occlusion. We report clinical, angiographical data and follow-up.

RESULTS

The population was composed of six patients (five males) with an average age of 64+/-7 years. Five patients were admitted with cardiogenic shock and four were mechanically ventilated. Distal occlusion of main left coronary artery and dominant right coronary artery were noted in all cases. Sub-occluded lesion of right coronary artery was noted in one case. Successful procedure with bare metal stent was achieved in five cases. Mortality rate was 66% (n=4): three patients died in hospital and another 1 or 2 months later of congestive heart failure. Coronary artery bypass grafting was performed at 4 and 12 months later for two patients. They are alive after 12 and 72 months of follow-up.

CONCLUSION

We demonstrate the feasibility of percutaneous coronary intervention of acute main left coronary occlusion. Inspite successful procedure, intrahospital mortality rate is still high and prognosis is related to cardiogenic shock.

Long-Term Prognosis in an ST-Segment Elevation Myocardial Infarction Population Treated With Routine Primary Percutaneous Coronary Intervention

Background— We sought to describe the long-term prognosis after routine primary percutaneous coronary intervention (pPCI) in a contemporary consecutive population of patients with presumed ST-segment elevation myocardial infarction, compare it with similar results from the landmark DANAMI-2 trial, and to identify a possible impact of time of presentation and referral pattern.

Methods and Results— Long-term prognosis in 1019 presumed ST-segment elevation myocardial infarction patients, treated according to modern routine pPCI during the year 2004, was analyzed and compared with similar data from the DANAMI-2 trial. Furthermore, we analyzed the impact of patient presentation to the angioplasty center during “off hours” (4 pm to 8 am plus weekends and holidays) and the impact of being referred from noninvasive hospitals. At 3 years, 20.4% in the routinely treated population versus 19.6% in the DANAMI-2 trial reached the combined end point of death, reinfarction, or stroke ( P =0.68), whereas the all-cause mortality was 13.0% and 13.7%, respectively ( P =0.65). Patients admitted during off hours had the same risk of reaching the combined end point of death, reinfarction, or stroke compared with patients admitted during office hours (hazards ratio, 1.04; 95% CI, 0.8 to 1.5; P =0.81). Door-to-balloon times of less than 90 minutes were achieved in 60% among patients admitted directly to an invasive center but only in 40% among transferred patients ( P <0.001). Despite this difference, no difference in unadjusted or adjusted long-term prognosis was found between the 2 groups.

Conclusions— This study shows that ST-segment elevation myocardial infarction patients treated with contemporary routine pPCI achieve a similar long-term prognosis as patients in the landmark randomized pPCI trial (DANAMI-2). Furthermore, the long-term prognosis was the same regardless of whether the pPCI was performed during off hours or office hours. Thus, pPCI including transportation of patients from noninvasive centers can be applied successfully in a real-life population.

Early abciximab administration before transfer for primary percutaneous coronary interventions for ST-elevation myocardial infarction reduces 1-year mortality in patients with high-risk profile. Results from EUROTRANSFER registry

BACKGROUND

There are conflicting data on the clinical benefit from early administration of abciximab from a large randomized trial and a registry. However, both sources suggest that a benefit may depend on the baseline risk profile of the patients. We evaluated the role of early abciximab administration in patients with ST-segment-elevation myocardial infarction (STEMI) referred for primary percutaneous coronary intervention stratified by the STEMI Thrombolysis In Myocardial Infarction (TIMI) risk score.

METHODS

A total of 1,650 patients were enrolled into the EUROTRANSFER Registry. One thousand eighty-six patients received abciximab (66%). Abciximab was administered early in 727 patients (EA) and late in 359 patients (LA). We used the TIMI risk score for risk stratification. Patients with scores >or=3 constituted the high-risk group of 616 patients (56.7%), whereas 470 patients formed the low-risk cohort. Factoring in the timing of the abciximab administration resulted in 4 groups of patients who were compared for mortality at 1 year: EA/high-risk (n = 413); LA/high-risk (n = 203); EA/low-risk (n = 314); LA/low-risk (n = 156). Baseline difference was accounted for by means of propensity score.

RESULTS

In high-risk patients, 1-year mortality was significantly lower with early abcximab compared to late administration (8.7% vs 15.8%; odds ratio 0.51, CI 0.31-0.85, P = .01). In multivariable Cox regression analysis, both early abciximab administration and patients' risk profile (TIMI score >or=3) were identified as independent predictors of 1-year mortality.

CONCLUSIONS

Early abciximab administration before transfer for percutaneous coronary intervention in STEMI shows lower mortality at 1-year follow-up. This effect is confined to patients with higher risk profile as defined by TIMI risk score >or=3.

Mortality of patients admitted to hospital with acute ST-elevation myocardial infarction, before and after the opening of primary percutaneous coronary intervention unit in Szombathely

Az akut szívizominfarktus kezelési stratégiája alapvetően megváltozott az elmúlt időszakban. Továbbra is vita tárgya a két reperfúziós stratégia, a primer percutan coronariaintervenció és a fibrinolízis összehasonlítása. Ha primer percutan coronariaintervenció elérhető, akkor ez a választandó kezelési stratégia ST-szegment-elevációval járó myocardialis infarctusban. Cél: Jelen cikkben a Szombathely városból ST-szegment-elevációval járó akut szívinfarktussal kórházba került betegek 3 hónapos halálozását vizsgáltuk. Módszer: Két időszakot hasonlítottunk össze, 2005-öt, amikor nem volt helyben percutan coronariaintervencióra alkalmas szívkatéteres laboratórium és 2008-at, amikor helyben rendelkezésre állt a primer percutan coronariaintervenció. Eredmények: A 12 órás ischaemiás időszaknál rövidebb betegcsoportban a 3 hónapos halálozás 2008-ban lényegesen alacsonyabb volt a 2005-ös évhez képest (3,6% versus 15,6%). Elsősorban a fibrinolízissel kezelt betegcsoport magas, három hónapos mortalitása volt felelős a különbségért. Ugyancsak fontos, hogy 2008-ban csökkent a 12 órán túli betegek aránya 2005-höz képest. Következtetés: A szívkatéteres labor létrehozása kedvező hatással volt Szombathely város ST-elevációs infarktusos betegeinek kórlefolyására.

Antithrombotics in acute coronary syndromes

Antithrombotic agents are an integral component of the medical regimens and interventional strategies currently recommended to reduce thrombotic complications in patients with acute coronary syndromes (ACS). Despite great advances with these therapies, associated high risks for thrombosis and hemorrhage remain as the result of complex interactions involving patient comorbidities, drug combinations, multifaceted dosing adjustments, and the intricacies of the care environment. As such, the optimal combinations of antithrombotic therapies, their timing, and appropriate targeted subgroups remain the focus of intense research. During the last several years a number of new antithrombotic treatments have been introduced, and new data regarding established therapies have come to light. Although treatment guidelines include the most current available data, subsequent findings can be challenging to integrate. This challenge is compounded by the complexity associated with different efficacy and safety measures and the variability in study populations, presenting syndromes, physician, and patient preferences. In this work we review recent data regarding clinically available antiplatelet and anticoagulation agents used in the treatment of patients with ACS. We address issues including relative efficacy, safety, and timing of therapies with respect to conservative and invasive treatment strategies. In specific cases we will highlight remaining questions and controversies and ongoing trials, which will hopefully shed light in these areas. In addition to reviewing existing agents, we take a look forward at the most promising new antithrombotics currently in late-stage clinical development and their potential role in the context of ACS management.

Efficacy and safety of immediate angioplasty versus ischemia-guided management after thrombolysis in acute myocardial infarction in areas with very long transfer distances results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-elevation myocardial infarction)

OBJECTIVES

The goal of this study was to compare a strategy of immediate transfer for percutaneous coronary intervention (PCI) with an ischemia-guided approach after thrombolysis in patients with very long transfer distances to PCI.

BACKGROUND

Thrombolysis remains the treatment of choice in ST-segment elevation myocardial infarction (STEMI) when primary PCI cannot be performed within 90 to 120 min. The optimal treatment after thrombolysis is still unclear.

METHODS

A total of 266 patients with acute STEMI living in rural areas with more than 90-min transfer delays to PCI were treated with tenecteplase, aspirin, enoxaparin, and clopidogrel and randomized to immediate transfer for PCI or to standard management in the local hospitals with early transfer, only if indicated for rescue or clinical deterioration. The primary outcome was a composite of death, reinfarction, stroke, or new ischemia at 12 months, and analysis was by intention to treat.

RESULTS

The primary end point was reached in 28 patients (21%) in the early invasive group compared with 36 (27%) in the conservative group (hazard ratio: 0.72, 95% confidence interval: 0.44 to 1.18, p = 0.19). The composite of death, reinfarction, or stroke at 12 months was significantly reduced in the early invasive compared with the conservative group (6% vs. 16%, hazard ratio: 0.36, 95% confidence interval: 0.16 to 0.81, p = 0.01). No significant differences in bleeding or infarct size were observed.

CONCLUSIONS

Immediate transfer for PCI did not improve the primary outcome significantly, but reduced the rate of death, reinfarction, or stroke at 12 months in patients with STEMI, treated with thrombolysis and clopidogrel in areas with long transfer distances. (Norwegian Study on District Treatment of ST-Elevation Myocardial Infarction; NCT00161005).

Ticagrelor versus clopidogrel in patients with acute coronary syndromes

BACKGROUND

Ticagrelor is an oral, reversible, direct-acting inhibitor of the adenosine diphosphate receptor P2Y12 that has a more rapid onset and more pronounced platelet inhibition than clopidogrel.

METHODS

In this multicenter, double-blind, randomized trial, we compared ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) and clopidogrel (300-to-600-mg loading dose, 75 mg daily thereafter) for the prevention of cardiovascular events in 18,624 patients admitted to the hospital with an acute coronary syndrome, with or without ST-segment elevation.

RESULTS

At 12 months, the primary end point--a composite of death from vascular causes, myocardial infarction, or stroke--had occurred in 9.8% of patients receiving ticagrelor as compared with 11.7% of those receiving clopidogrel (hazard ratio, 0.84; 95% confidence interval [CI], 0.77 to 0.92; P<0.001). Predefined hierarchical testing of secondary end points showed significant differences in the rates of other composite end points, as well as myocardial infarction alone (5.8% in the ticagrelor group vs. 6.9% in the clopidogrel group, P=0.005) and death from vascular causes (4.0% vs. 5.1%, P=0.001) but not stroke alone (1.5% vs. 1.3%, P=0.22). The rate of death from any cause was also reduced with ticagrelor (4.5%, vs. 5.9% with clopidogrel; P<0.001). No significant difference in the rates of major bleeding was found between the ticagrelor and clopidogrel groups (11.6% and 11.2%, respectively; P=0.43), but ticagrelor was associated with a higher rate of major bleeding not related to coronary-artery bypass grafting (4.5% vs. 3.8%, P=0.03), including more instances of fatal intracranial bleeding and fewer of fatal bleeding of other types.

CONCLUSIONS

In patients who have an acute coronary syndrome with or without ST-segment elevation, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death from vascular causes, myocardial infarction, or stroke without an increase in the rate of overall major bleeding but with an increase in the rate of non-procedure-related bleeding. (ClinicalTrials.gov number, NCT00391872.)

Clinical impact of thrombectomy in acute ST-elevation myocardial infarction: an individual patient-data pooled analysis of 11 trials

AIMS

Thrombectomy in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is associated to better myocardial reperfusion. However, no single trial was adequately powered to asses the impact of thrombectomy on long-term clinical outcome and to identify patients at higher benefit. Thus, we sought to assess these issues in a collaborative individual patient-data pooled analysis of randomized studies (study acronym: ATTEMPT, number of registration: NCT00766740).

METHODS AND RESULTS

Individual data of 2686 patients enrolled in 11 trials entered the pooled analysis. Primary endpoint of the study was all-cause mortality. Major adverse cardiac events (MACE) were considered as the occurrence of all-cause death and/or target lesion/vessel revascularization and/or myocardial infarction (MI). Subgroups analysis was planned according to type of thrombectomy device (manual or non-manual), diabetic status, IIb/IIIa-inhibitor therapy, ischaemic time, infarct-related artery, pre-PCI TIMI flow. Clinical follow-up was available in 2674 (99.6%) patients at a median of 365 days. Kaplan-Meier analysis showed that allocation to thrombectomy was associated with significantly lower all-cause mortality (P = 0.049). Thrombectomy was also associated with significantly reduced MACE (P = 0.011) and death + MI rate during the follow-up (P = 0.015). Subgroups analysis showed that thrombectomy is associated to improved survival in patients treated with IIb/IIIa-inhibitors (P = 0.045) and that the survival benefit is confined to patients treated in manual thrombectomy trials (P = 0.011).

CONCLUSION

The present large pooled analysis of randomized trials suggests that thrombectomy (in particular manual thrombectomy) significantly improves the clinical outcome in patients with STEMI undergoing mechanical reperfusion and that its effect may be additional to that of IIb/IIIa-inhibitors.

Unprotected left main revascularization in patients with acute coronary syndromes

AIMS

In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary disease (ULMCD) has been little studied. The objectives of the present study were to describe the practice of ULMCD revascularization in ACS patients and its evolution over an 8-year period, analyse the prognosis of this population and determine the effect of revascularization on outcome.

METHODS AND RESULTS

Of 43 018 patients enrolled in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007, 1799 had significant ULMCD and underwent percutaneous coronary intervention (PCI) alone (n = 514), coronary artery bypass graft (CABG) alone (n = 612), or no revascularization (n = 673). Mortality was 7.7% in hospital and 14% at 6 months. Over the 8-year study, the GRACE risk score remained constant, but there was a steady shift to more PCI than CABG over time. Patients undergoing PCI presented more frequently with ST-segment elevation myocardial infarction (STEMI), after cardiac arrest, or in cardiogenic shock; 48% of PCI patients underwent revascularization on the day of admission vs. 5.1% in the CABG group. After adjustment, revascularization was associated with an early hazard of hospital death vs. no revascularization, significant for PCI (hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.62-4.18) but not for CABG (1.26, 0.72-2.22). From discharge to 6 months, both PCI (HR 0.45, 95% CI 0.23-0.85) and CABG (0.11, 0.04-0.28) were significantly associated with improved survival in comparison with an initial strategy of no revascularization. Coronary artery bypass graft revascularization was associated with a five-fold increase in stroke compared with the other two groups.

CONCLUSION

Unprotected left main coronary disease in ACS is associated with high mortality, especially in patients with STEMI and/or haemodynamic or arrhythmic instability. Percutaneous coronary intervention is now the most common revascularization strategy and preferred in higher risk patients. Coronary artery bypass graft is often delayed and performed in lower risk patients, leading to good 6-month survival. The two approaches therefore appear complementary.

The DD genotype of the angiotensin converting enzyme gene independently associates with CMR-derived abnormal microvascular perfusion in patients with a first anterior ST-segment elevation myocardial infarction treated with thrombolytic agents

INTRODUCTION

The role of the angiotensin converting enzyme (ACE) gene on the result of thrombolysis at the microvascular level has not been addressed so far. We analyzed the implications of the insertion/deletion (I/D) polymorphism of the ACE gene on the presence of abnormal cardiovascular magnetic resonance (CMR)-derived microvascular perfusion after ST-segment elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

We studied 105 patients with a first anterior STEMI treated with thrombolytic agents and an open left anterior descending artery. Microvascular perfusion was assessed using first-pass perfusion CMR at 7+/-1 days. CMR studies were repeated 184+/-11 days after STEMI. The ACE gene insertion/deletion (I/D) polymorphism was determined using polymerase chain reaction amplification.

RESULTS

Overall genotype frequencies were II-ID 58% and DD 42%. Abnormal perfusion (> or = 1 segment) was detected in 56% of patients. The DD genotype associated to a higher risk of abnormal microvascular perfusion (68% vs. 47%, p=0.03) and to a larger extent of perfusion deficit (median [percentile 25 - percentile 75]: 4 [0-6] vs. 0 [0-4] segments, p=0.003). Once adjusted for baseline characteristics, the DD genotype independently increased the risk of abnormal microvascular perfusion (odds ratio [95% confidence intervals]: 2.5 [1.02-5.9], p=0.04). Moreover, DD patients displayed a larger infarct size (35+/-17 vs. 27+/-15 g, p=0.01) and a lower ejection fraction at 6 months (48+/-14 vs. 54+/-14%, p=0.03).

CONCLUSIONS

The DD genotype associates to a higher risk of abnormal microvascular perfusion after STEMI.

Prehospital fibrinolytic therapy followed by urgent percutaneous coronary intervention in patients with ST-elevation myocardial infarction

In patients with ST-segment elevation myocardial infarction (STEMI) the shorter the reperfusion time, the better the outcome is, regardless of the reperfusion method. Effective, early and rapid reperfusion is the most important goal in the treatment of patients with STEMI. In majority cases of STEMI, transport or transfer to a percutaneous coronary intervention (PCI)-capable center will occur, sometimes bypassing the closest hospital facilities that are not PCI centers. The timely optimal reperfusion strategy might be a prehospital initiated pharmacological reperfusion with subsequent PCI. Reduced-dose prehospital fibrinolysis allows safe transport of STEMI patients to PCI centers for urgent culprit artery PCI, and may be a superior approach compared with transporting patients to the closest non-PCI hospital for fibrinolytic therapy. In this review we will discuss the evidence regarding reperfusion strategies in STEMI patients.

[Ivabradine - a new therapeutic option for cardiogenic shock?]

Documented mortality from acute myocardial infarction (AMI) has significantly decreased from around 30% in the 1960s to currently 6-7%, following the introduction of intensive-care treatment, thrombolysis, effective antithrombotic therapy, and coronary angioplasty. However, the approximate mortality of 70-80% of patients with cardiogenic shock following AMI has hardly improved despite the introduction of modern treatment strategies. The major cause of in-hospital AMI mortality remains myocardial failure with consecutive cardiogenic shock and multiorgan failure. Reduction of heart rate is one of the most important energy-saving maneuvers, which can be achieved by administration of beta-receptor-blocking agents. In patients with clinical signs of hypotension, however, the guidelines recommend to stabilize the patient before administering an oral beta-receptor blocker, mainly because of the hypotensive effects of the substance class. In this situation, selective heart rate reduction, e.g., via administration of ivabradine without side effects of hypotension may be advantageous and better tolerated in patients with cardiogenic shock. The aim of the present review is to briefly summarize the treatment options of cardiogenic shock and the mechanisms of action of ivabradine as well as to present a case report of a patient with cardiogenic shock due to main trunk occlusion, where treatment with ivabradine seemed to beneficially influence the outcome.

[Acute myocardial infarction: acute coronary intervention at any hospital versus acute coronary intervention at specialized centers only]

The acute coronary syndromes (ACS) are currently divided into those with ST elevation (STE-ACS = ST elevation myocardial infarction [STEMI]) and those without ST elevation (NSTE-ACS). The latter are further divided into NSTE-ACS with risk factors and NSTE-ACS without risk factors. For NSTE-ACS patients with risk factors an invasive strategy within 72 h after presentation is recommended, whereas NSTE-ACS patients without risk factors can be treated conservatively, without a routine invasive diagnosis. In patients with STE-ACS, primary angioplasty is the reperfusion therapy of choice. These recommendations concerning the invasive strategies are valid only under three conditions: (1) primary angioplasty has to be performed within 2 h after diagnosis of an STE-ACS; (2) door-to-balloon times for STE-ACS have to be < 60 min; (3) the invasive procedures have to be performed by experienced investigators at hospitals with a sufficient annual PCI (percutaneous coronary intervention) volume. The last point is based on studies which showed a volume-outcome relationship for PCIs in ACS patients and hospital mortality. In Germany, a nationwide supply with such an invasive strategy for ACS patients is currently possible, even within the recommended time frames. Therefore, local networks have to be established to achieve this goal. However, at least in regions with a high density of invasive centers, such networks should take the investigators' experience and the annual interventional volumes of the participating hospitals into account.

Primary Percutaneous Coronary Angioplasty With and Without Eptifibatide in ST-Segment Elevation Myocardial Infarction

Background— Primary percutaneous coronary intervention, if performed promptly, is the preferred strategy to restore flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. We sought to determine whether eptifibatide, a platelet glycoprotein IIb/IIIa inhibitor, given before catheterization would improve clinical outcomes in patients referred for primary percutaneous coronary intervention.

Methods and Results— We randomly assigned a total of 400 patients with ST-segment elevation myocardial infarction referred for primary percutaneous coronary intervention to treatment initiated before cardiac catheterization, with either heparin plus eptifibatide (201 patients) or heparin alone (199 patients), in addition to oral aspirin (160 mg) and high-dose clopidogrel (600 mg). The primary end point was a composite of death from any cause, recurrent myocardial infarction, or recurrent severe ischemia during the first 30 days after randomization. At 30 days, the primary end point was reached by 13 patients (6.47%) assigned to heparin plus eptifibatide and by 11 patients (5.53%) assigned to heparin alone (relative risk, 1.18; 95% CI, 0.52 to 2.70; P =0.69). The rates of major or minor bleeding were higher in patients assigned to heparin plus eptifibatide than that in patients assigned to heparin alone (22.4% versus 14.6%; relative risk, 1.69; 95% CI, 1.01 to 2.83; P =0.04).

Conclusions— In patients pretreated with high-dose clopidogrel who were referred for primary PCI, treatment with heparin plus eptifibatide, when compared with heparin alone, did not improve clinical outcomes and was associated with more bleeding complications.

Effect of high-dose intracoronary adenosine administration during primary percutaneous coronary intervention in acute myocardial infarction: a randomized controlled trial

BACKGROUND

Coronary microvascular dysfunction is frequently seen in patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention. Previous studies have suggested that the administration of intravenous adenosine resulted in an improvement of myocardial perfusion and a reduction in infarct size. Intracoronary adenosine (bolus of 30 to 60 microg) is a guideline-recommended therapy to improve myocardial reperfusion. The effect of intracoronary adenosine during primary percutaneous coronary intervention has not been investigated in a large randomized trial.

METHODS AND RESULTS

Patients presenting with acute ST-elevation myocardial infarction were randomized to 2 bolus injections of intracoronary adenosine (2 x 120 microg in 20 mL NaCl) or placebo (2 x 20 mL NaCl). The first bolus injection was given after thrombus aspiration and the second after stenting of the infarct-related artery. The primary end point was the incidence of residual ST-segment deviation <0.2 mV, 30 to 60 minutes after percutaneous coronary intervention. Secondary end points were ST-segment elevation resolution, myocardial blush grade, Thrombolysis in Myocardial Infarction flow on the angiogram after percutaneous coronary intervention, enzymatic infarct size, and clinical outcome at 30 days. A total of 448 patients were randomized to intracoronary adenosine (N=226) or placebo (N=222). The incidence of residual ST-segment deviation <0.2 mV did not differ between patients randomized to adenosine or placebo (46.2% versus 52.2%, P=NS). In addition, there were no significant differences in secondary outcome measures.

CONCLUSIONS

In this randomized placebo controlled trial enrolling 448 patients with ST-elevation myocardial infarction, administration of intracoronary adenosine after thrombus aspiration and after stenting of the infarct-related artery did not result in improved myocardial perfusion.

One scan for all: extended role of cardiac CT angiography in acute myocardial infarction

BACKGROUND

Cardiac computed-tomographic angiography (CTA) has gained widespread acceptance as a useful non-invasive technique in the assessment of coronary artery disease. Although most interest has focused on coronary vessels, analysis of myocardial perfusion, left ventricular wall motion, ejection fraction and left ventricular structure can easily be performed at the same time allowing comprehensive assessment of anatomy and function in a single examination. We present a case of acute ST elevation myocardial infarction where cardiac catheterization was deferred, but assessment by CTA permitted a management plan to be constructed using rest perfusion and blood pool inversion analyses of the dataset obtained during the coronary artery study.

CONCLUSION

Coronary CT angiography can provide a comprehensive assessment of coronary arteries, myocardial perfusion and structural features in those not suitable for coronary angiography after myocardial infarction.

Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials

AIMS

Studies have compared safety and efficacy of percutaneous left ventricular assist devices (LVADs) with intra-aortic balloon pump (IABP) counterpulsation in patients with cardiogenic shock. We performed a meta-analysis of controlled trials to evaluate potential benefits of percutaneous LVAD on haemodynamics and 30-day survival.

METHODS AND RESULTS

Two independent investigators searched Medline, Embase, and Cochrane Central Register of Controlled Trials for all controlled trials using percutaneous LVAD in patients with cardiogenic shock, where after data were extracted using standardized forms. Weighted mean differences (MDs) were calculated for cardiac index (CI), mean arterial pressure (MAP), and pulmonary capillary wedge pressure (PCWP). Relative risks (RRs) were calculated for 30-day mortality, leg ischaemia, bleeding, and sepsis. In main analysis, trials were combined using inverse-variance random effects approach. Two trials evaluated the TandemHeart and a recent trial used the Impella device. After device implantation, percutaneous LVAD patients had higher CI (MD 0.35 L/min/m(2), 95% CI 0.09-0.61), higher MAP (MD 12.8 mmHg, 95% CI 3.6-22.0), and lower PCWP (MD -5.3 mm Hg, 95% CI -9.4 to -1.2) compared with IABP patients. Similar 30-day mortality (RR 1.06, 95% CI 0.68-1.66) was observed using percutaneous LVAD compared with IABP. No significant difference was observed in incidence of leg ischaemia (RR 2.59, 95% CI 0.75-8.97) in percutaneous LVAD patients compared with IABP patients. Bleeding (RR 2.35, 95% CI 1.40-3.93) was significantly more observed in TandemHeart patients compared with patients treated with IABP.

CONCLUSION

Although percutaneous LVAD provides superior haemodynamic support in patients with cardiogenic shock compared with IABP, the use of these more powerful devices did not improve early survival. These results do not yet support percutaneous LVAD as first-choice approach in the mechanical management of cardiogenic shock.

C-reactive protein improves risk prediction in patients with acute coronary syndromes

AIMS

Elevated C-reactive protein level is a risk marker in patients with acute coronary syndromes (ACSs), but current risk score systems do not consider this factor. We studied the incremental predictive value of adding C-reactive protein to the Global Registry of Acute Coronary Events (GRACE) risk score.

METHODS AND RESULTS

Characteristics, treatments and 30-day mortality were recorded for 1408/1901 consecutive ACS patients. Changes in global model fit, discrimination, calibration, and reclassification were evaluated upon addition of C-reactive protein to the GRACE risk score. High-C-reactive protein patients (C-reactive protein >22 mg/L, 4th quartile of C-reactive protein) were older, had more comorbidities and worse haemodynamic conditions, received less recommended treatment, and had a four-fold higher 30 day mortality. Multivariable analysis demonstrated high-C-reactive protein as an important and independent predictor of mortality. Addition of high-C-reactive protein in the GRACE model modestly improved global fit, discriminatory capacity (c-statistic from 0.795 to 0.823), and calibration. Patients were divided into four groups according to GRACE risk score prediction: <1, 1 to <5, 5 to <10, and >or=10%. The model with high-C-reactive protein allowed adequate reclassification in 12.2%.

CONCLUSION

Elevated C-reactive protein level is a modest but independent predictive factor of 30-day mortality in ACS patients, even after adjustment for co-morbidities, haemodynamic conditions, and treatment. Combined with the GRACE risk score, C-reactive protein information improves risk classification.

Omacor (prescription omega-3-acid ethyl esters 90): From severe rhythm disorders to hypertriglyceridemia

Despite progress made in post-myocardial infarction (MI) revascularization and background therapy for the failing heart, the prevention of adverse cardiac remodeling associated with severe rhythm disorders remains an important drug target. Part of the remodeling can be counteracted by modulating the activity of ion channels and exchangers by omega-3 acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). In the GISSI-Prevenzione and GISSI-HF trials, omega-3 fatty acids were administered as ethyl esters (Omacor Solvay Pharmaceuticals) and not as triglycerides present in fish oil. Ethyl esters result in a sustained intestinal absorption of EPA and DHA and require various purification steps during production, thereby minimizing the content of environmental toxins. Also the rather high (38%) DHA content of Omacor should not be ignored since in rats with low dose intake of omega-3 acids, DHA but not EPA inhibited ischemia-induced arrhythmias. In patients on multiple tablets, 840 mg EPA+DHA in one capsule is preferred to increase compliance. It is not justified to refer to Omacor as "n-3 polyunsaturated fatty acid supplementation" or even "fish oil" and, based on controlled clinical trials, there is no evidence that fish oil could be a substitute of Omacor. To avoid further confusion, guidelines should be precise and refer to the medication, eg, as in NICE guideline CG48: "Omega-3-acid ethyl esters treatment licensed for secondary prevention post-MI." The anti-arrhythmogenic action of Omacor should be seen in the context of implantable cardioverter-defibrillator trials (DINAMIT, IRIS) where non-sudden death was increased and total mortality unaltered. However, Omacor administered in the GISSI-HF trial reduced the incidence of severe arrhythmic events and mortality. Also in the GISSI-Prevenzione trial, arrhythmic death and mortality were reduced. At higher dosages (daily, 3-4 g) Omacor exhibits more pronounced cardiovascular benefits and, as a licensed indication, improves hypertriglyceridemia and related lipid parameters.

[Perioperative myocardial damage in non-cardiac surgery patients]

Perioperative myocardial damage occurs with a high incidence depending on the operative procedure and the patients examined and is considered to be among the most relevant risk factors for increased perioperative morbidity and mortality in patients undergoing non-cardiac surgery. The pathophysiology of myocardial damage in the perioperative period is still not well understood. Both ischemia with and without acute coronary occlusion and non-ischemic stimuli can put a substantial strain on the heart in the perioperative period. However, in many cases the clinical presentation does not allow a clear differentiation between ischemic and non-ischemic myocardial damage. In the majority of cases perioperative myocardial infarctions occur with only mild or even without any clinical symptoms. This is probably due to a considerable difference in phenotype and pathophysiology between perioperative and non-perioperative myocardial infarctions. As a result of this unexplained etiology of perioperative myocardial infarction it remains an open question whether the contemporary diagnostic and therapeutic recommendations for the acute coronary syndrome can be extrapolated to the perioperative situation. The present review reflects the current state of knowledge and presents an optional approach to the diagnosis and therapy of perioperative myocardial injury.