Treatment of silent ischemia in unstable angina: a randomized comparison of sustained-release verapamil versus metoprolol

Failed reperfusion after thrombolytic therapy: recognition and management

BACKGROUND

Failed reperfusion after thrombolysis occurs in as many as 30% of patients with acute myocardial infarction (MI). Furthermore, some patients have incomplete tissue perfusion despite reperfusion of the infarct-related artery. Close assessment of the efficacy of thrombolytic administration in people with evolving acute MI is necessary, particularly with regard to myocardial perfusion status, because some patients may benefit from incremental pharmacologic or invasive reperfusion strategies.

PURPOSE AND METHOD

This article reviews a number of strategies to assess infarct-related artery patency and myocardial tissue perfusion. These include coronary angiography, continuous ST-segment monitoring, serial electrocardiography, obtaining serial serum biochemical markers of myocardial necrosis, monitoring for reperfusion arrhythmias, and assessment of changes in chest pain intensity.

CONCLUSION

The early detection of failed reperfusion is critical if incremental strategies to enhance myocardial salvage are to be considered. Continuous ST-segment monitoring is a relatively inexpensive, reliable, and accurate tool for assessing real-time myocardial perfusion.

Health outcomes associated with beta-blocker and diltiazem treatment of unstable angina

OBJECTIVE

We compared long-term health outcomes associated with beta-adrenergic blocking agents and diltiazem treatment for unstable angina.

BACKGROUND

No long-term data have been published comparing these two antianginal treatments in this setting.

METHODS

Eligible veterans were discharged from the Veterans Affairs Puget Sound Health Care System (VAPSHCS), Seattle Division, between October 1989 and September 1995 with an unstable angina diagnosis and were prescribed monotherapy beta-blocker or diltiazem treatment at discharge. Medication data were collected from medical records and computerized VAPSHCS outpatient pharmacy files. Follow-up death and coronary artery disease rehospitalization data were collected through 1996. Proportional hazards regression compared survival among diltiazem and beta-blocker users, controlling for patient characteristics with propensity scores.

RESULTS

Two hundred forty-seven veterans (24% on beta-blockers, 76% on diltiazem) were included in this study. There were 54 (22%) deaths during an average follow-up of 51 months. After propensity score adjustment, there was no difference in risk of death comparing diltiazem to beta-blocker treatment (hazards ratios [HR] 1.1; 95% confidence interval [CI] 0.49 to 2.4). Among Washington residents (n=207), there were 146 (71%) coronary artery disease rehospitalizations or deaths during follow-up. After adjustment, there was a nonsignificant increase in risk of rehospitalization or death associated with diltiazem use (HR 1.4; 95% CI 0.80 to 2.4). For both analyses, similar risks were found among veterans without relative contraindications to beta-blockers.

CONCLUSIONS

We found no survival benefit of diltiazem over beta-blocker treatment for unstable angina in this cohort of veterans.