Facilitated percutaneous coronary intervention versus primary percutaneous coronary intervention: design and rationale of the Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events (FINESSE) trial

Antiplatelet Agents in Acute ST Elevation Myocardial Infarction

Platelet aggregation and thrombus formation represent the basic mechanism for clinical, electrocardiographic, and biomarker changes consistent with acute coronary syndrome. Various oral and intravenous formulations of platelet function inhibitors have been developed to help decrease platelet aggregation due to acute atherosclerotic plaque rupture. In this article, we review the various mechanisms, pharmacokinetics/pharmacodynamics, and the key clinical trials related to the platelet inhibitors that form the basis for current recommendations of their use in the ST elevation myocardial infarction guidelines by the American College of Cardiology/American Heart Association.

Echocardiographic Parameters as Life Quality Predictors in Patients After Myocardial Infarction Treated with Different Methods

INTRODUCTION

Cardiovascular diseases are the leading cause of death in most countries. The aim was to examine the quality of life and to determine the differences in the quality of life in patients one year after myocardial infarction and the relationship between quality of life and echocardiographic parameters in these patients.

MATERIAL AND METHODS

The research was a prospective, clinical, epidemiological study and was conducted at the Clinic of Cardiology, University Clinical Center Sarajevo (UCCS). The research was conducted on a sample of 160 patients who had acute myocardial infarction, which are based on the therapeutic procedures divided into four groups. The average age in the total sample was 54.9±8.8 years (range 37-76 years). The research was conducted one year after myocardial infarction (I group of subjects) or 12 months after PCI therapeutic procedures (II and III group of respondents) or coronary artery bypass surgery (IV group of respondents).

RESULTS

Comparison of the mean scores of scales in SF-36 questionnaire showed that the highest total score had patients in the group II 67.3±15.2, and the lowest in the group I 57.8±21.4. The increase in ejection fraction leads to a statistically significant increase in quality of life scores at all subscales, in all groups, so that EF has the greatest impact on the quality of life in all respondents. Statistically significant differences in the effects of mitral regurgitation in particular groups have been recorded only in the case of the mental health scale.

CONCLUSIONS

Ejection fraction has the greatest impact on the quality of life in all patients, regardless of the type of medical treatment.

Reperfusion Options for ST Elevation Myocardial Infarction Patients with Expected Delays to Percutaneous Coronary Intervention

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST elevation myocardial infarction (STEMI). However, only one-third of hospitals in the US have PCI availability 24/7. For non-PCI hospitals, transfer remains the optimal strategy. For expected delays of greater than 120 minutes, a pharmacoinvasive strategy is recommended. In patients with evidence of failed reperfusion or hemodynamic instability, immediate rescue PCI should be performed. All other patients should undergo routine cardiac catheterization and PCI within 24 hours after fibrinolysis. A pharmacoinvasive strategy is best implemented within an organized regional STEMI system with prospective standardized transfer protocols.

Management and outcomes of patients presenting with STEMI by use of chronic oral anticoagulation: results from the GRACE registry

AIMS

To describe the characteristics, treatment, and mortality in patients with ST-elevation myocardial infarction (STEMI) by use of chronic oral anticoagulant (OAC) therapy.

METHODS

Using data from the Global Registry of Acute Coronary Syndromes (GRACE), patient characteristics, treatment, and reperfusion strategies of STEMI patients on chronic OAC are described, and relevant variables compared with patients not on chronic OAC. Six-month post-discharge mortality rates were evaluated by Cox proportional hazard models.

RESULTS

Of 19,094 patients with STEMI, 574 (3.0%) were on chronic OAC at admission. Compared with OAC non-users, OAC users were older (mean age 73 vs. 65 years), more likely to be female (37 vs. 29%), were more likely to have a history of atrial fibrillation, prosthetic heart valve, venous thromboembolism, or stroke/transient ischaemic attack, had a higher mean GRACE risk score (166 vs. 145), were less likely to be Killip class I (68 vs. 82%), and were less likely to undergo catheterization/percutaneous coronary intervention (52 vs. 66%, respectively). Of the patients who underwent catheterization, fewer OAC users had the procedure done within 24 h of admission (56.5 vs. 64.5% of OAC non-users). In propensity-matched analyses (n=606), rates of in-hospital major bleeding and in-hospital and 6-month post-discharge mortality were similar for OAC users and OAC non-users (2.7 and 3.7%, p=0.64; 15 and 13%, p=0.56; 15 and 12%, p=0.47, respectively), rates of in-hospital recurrent myocardial infarction (8.6 and 2.0%, p<0.001) and atrial fibrillation (32 and 22%, p=0.004) were higher in OAC patients, and rates of 6-month stroke were lower (0.6 and 4.3%, p=0.038). Patients in both groups who underwent catheterization had lower mortality than those who did not undergo catheterization.

CONCLUSIONS

This is the largest study to describe the characteristics and treatment of STEMI patients on chronic OAC. The findings suggest that patients on chronic OAC are less likely to receive guideline-indicated management, but have similar adjusted rates of in-hospital and 6-month mortality.

Association of initial thrombolysis in myocardial infarction flow grade with mortality among patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a National Registry of Myocardial Infarction-5 (NRMI-5) analysis

BACKGROUND

Initial epicardial coronary flow, as assessed by the Thrombolysis in Myocardial Infarction flow grade (TFG), prior to primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) has been associated with short- and long-term mortality in randomized clinical trials. This study was designed to determine the relationship between initial TFG and mortality in a large, heterogeneous, real-world population of STEMI patients undergoing pPCI.

METHODS

The relationship between pre-pPCI TFG among patients undergoing pPCI and in-hospital mortality was evaluated among STEMI patients from 2004 to 2006 in the National Registry of Myocardial Infarction.

RESULTS

Of 8,337 STEMI patients, 6,595 (79.1%) had pre-pPCI TFG 0/1, 1,126 (13.5%) had pre-pPCI TFG 2, and 616 (7.4%) had pre-pPCI TFG 3. TFG 0/1 prior to pPCI was associated with 3.4% in-hospital mortality, whereas TFG 2 (2.0%) and TFG 3 (1.8%) were associated with significantly lower mortality (TFG 0/1 vs TFG 2, P = .013; TFG 0/1 vs TFG 3, P = .035). TFG 0/1 prior to pPCI was also associated with a significant increase in the composite of death, recurrent myocardial infarction, heart failure, and shock (16.1%) when compared with patients presenting with TFG 2 (11.5%; P < .001) and TFG 3 (7.6%; P < .001). The difference in this composite was also significant between patients presenting with TFG 2 and TFG 3 (P = .01).

CONCLUSIONS

In a large, heterogeneous group of real-world patients presenting with STEMI, pre-pPCI TFG 0/1 is associated with higher in-hospital mortality and other major adverse cardiovascular events. These results corroborate prior to post hoc analyses from randomized clinical trials and support continued efforts aimed at safely establishing early infarct-related artery patency among patients with STEMI.

Safety and efficacy of abciximab as an adjunct to percutaneous coronary intervention

Abciximab is a widely studied glycoprotein IIb/IIIa inhibitor, specifically in the setting of patients undergoing percutaneous coronary intervention (PCI). The populations studied have included patients with non-ST-segment acute coronary syndromes, ST-segment elevation myocardial infarction, and elective PCI. This large amount of information provides a clear efficacy and safety profile of the drug, although a few questions on the use of abciximab still exist, particularly on its use and preference in the setting of newer antiplatelet and antithrombotic medications. In this article we review the most relevant data from randomized clinical trials with abciximab in patients undergoing PCI and discuss the recent guideline recommendation on use during PCI.

Upfront thrombus aspiration in primary coronary intervention for patients with ST-segment elevation acute myocardial infarction: report of the VAMPIRE (VAcuuM asPIration thrombus REmoval) trial

OBJECTIVES

This study evaluated safety and efficacy of upfront thrombus aspiration during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Distal embolization during primary PCI results in reduced myocardial perfusion and poor clinical outcomes.

METHODS

The VAMPIRE (VAcuuM asPIration thrombus REmoval) study was a prospective, randomized, controlled multicenter trial conducted in 23 institutions. Patients (N = 355) presenting within 24 h of STEMI symptoms onset were randomized to primary PCI with (n = 180) or without (n = 175) upfront thrombus aspiration using Nipro's TransVascular Aspiration Catheter (Osaka, Japan).

RESULTS

The TransVascular Aspiration Catheter reached the lesion in 100% of cases. It successfully crossed the target obstruction in 86% without any delay in procedure time or time to reperfusion; whereas macroscopic thrombi were removed in 75% of the cases. Procedure success was similar between groups (98.9% vs. 98.3%). There was a trend toward lower incidence of slow or no reflow (primary end point-defined as a Thrombolysis In Myocardial Infarction flow grade <3) in patients treated with aspiration versus conventional primary PCI (12.4% vs. 19.4%, p = 0.07). Rate of myocardial blush grade 3 was higher in the aspiration group (46.0% vs. 20.5%, p < 0.001). Aspiration was most effective in patients presenting after 6 h of symptoms onset (slow flow rate: 8.1% vs. 37.6%, p = 0.01).

CONCLUSIONS

This study suggested the safety of primary PCI with upfront thrombectomy using a novel device in patients with STEMI. The study showed a trend toward improved myocardial perfusion and lower clinical events in patients treated with aspiration. Patients presenting late after STEMI appear to benefit the most from thrombectomy.

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: potential benefits and future challenges

BACKGROUND

Facilitated percutaneous coronary intervention (PCI) is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors to minimize myocardial ischemia time while waiting for PCI. A pooled meta-analysis suggested that facilitated PCI was associated with higher rates of mortality and morbidity compared with nonfacilitated PCI.

OBJECTIVE

The heterogeneous and complex trials of facilitated PCI were systematically reviewed to identify where this strategy may be beneficial and deserving of further research.

METHODS

MEDLINE, EMBASE, the Cochrane database, the Internet and conference proceedings were searched to obtain relevant trials. Human studies that randomly assigned patients to fibrinolytic-facilitated PCI (administration of fibrinolytic therapy alone or in combination with GP IIb/IIIa inhibitors before angiography) versus nonfacilitated PCI were included.

RESULTS

Nine trials encompassing 3836 patients were reviewed. The facilitated PCI strategy was fibrinolytic therapy alone in seven trials and half-dose fibrinolytic therapy plus GP IIb/IIIa inhibitors in two trials. In patients who had fibrinolysis less than 2 h after symptom onset (mainly in the prehospital setting) and/or slightly delayed PCI 3 h to 24 h after fibrinolysis, facilitated PCI was associated with the greatest Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow and a trend toward reduced mortality. Overall, facilitated PCI was associated with increased intracranial hemorrhage and reinfarction. Combining half-dose fibrinolytic therapy and GP IIb/IIIa inhibitors reduced reinfarction but increased major bleeding.

CONCLUSIONS

Facilitated PCI cannot be recommended outside of experimental protocols at this time. Further research should focus on selecting patients with higher benefit-to-risk ratios and performing prehospital fibrinolysis with optimal antiplatelet or antithrombin therapy, as well as slightly delayed PCI in patients who are stable or geographically removed from PCI facilities.

Facilitated PCI in patients with ST-elevation myocardial infarction

BACKGROUND

We hypothesized that percutaneous coronary intervention (PCI) preceded by early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or with abciximab alone (abciximab-facilitated PCI) would improve outcomes in patients with acute ST-segment elevation myocardial infarction, as compared with abciximab administered immediately before the procedure (primary PCI).

METHODS

In this international, double-blind, placebo-controlled study, we randomly assigned patients with ST-segment elevation myocardial infarction who presented 6 hours or less after the onset of symptoms to receive combination-facilitated PCI, abciximab-facilitated PCI, or primary PCI. All patients received unfractionated heparin or enoxaparin before PCI and a 12-hour infusion of abciximab after PCI. The primary end point was the composite of death from all causes, ventricular fibrillation occurring more than 48 hours after randomization, cardiogenic shock, and congestive heart failure during the first 90 days after randomization.

RESULTS

A total of 2452 patients were randomly assigned to a treatment group. Significantly more patients had early ST-segment resolution with combination-facilitated PCI (43.9%) than with abciximab-facilitated PCI (33.1%) or primary PCI (31.0%; P=0.01 and P=0.003, respectively). The primary end point occurred in 9.8%, 10.5%, and 10.7% of the patients in the combination-facilitated PCI group, abciximab-facilitated PCI group, and primary-PCI group, respectively (P=0.55); 90-day mortality rates were 5.2%, 5.5%, and 4.5%, respectively (P=0.49).

CONCLUSIONS

Neither facilitation of PCI with reteplase plus abciximab nor facilitation with abciximab alone significantly improved the clinical outcomes, as compared with abciximab given at the time of PCI, in patients with ST-segment elevation myocardial infarction. (ClinicalTrials.gov number, NCT00046228 [ClinicalTrials.gov].)

Emergency coronary artery bypass grafting in patients with acute myocardial infarction treated with glycoprotein IIb/IIIa receptor inhibitors

Glycoprotein (GP) IIb/IIIa receptor inhibitors before primary angioplasty in patients with ST-elevation acute myocardial infarction (STEMI) are recommended by current guidelines. Thus, an increasing number of patients receive these drugs before coronary angiography, particularly if a between-hospital transfer is needed. However, when coronary anatomy is unsuitable for angioplasty, emergency coronary artery bypass grafting (CABG) under GP IIb/IIIa inhibitor treatment may be needed, with a potential increase in bleeding risk. Abciximab has a long duration of action, because of its high-affinity binding to GP IIb/IIIa receptors. Initial retrospective studies reported a higher incidence of major bleeding during emergency CABG after abciximab administration, leading to the recommendation of delaying surgery >12 h. However, data from the prospective trials on abciximab do not confirm the increase in bleeding risk, and current evidence shows that emergency surgery can be performed safely soon after abciximab cessation. Monitoring of activated clotting time during surgery and platelet transfusion in case of postoperative relevant bleeding are the only measures needed. No data are available on emergency surgery in patients with STEMI treated with eptifibatide or tirofiban. However, their short-lasting effects and the results of trials on non-ST-elevation acute coronary syndromes suggest that they could even reduce postoperative bleeding by preventing platelet consumption during cardiopulmonary bypass. In conclusion, the early administration of GP IIb/IIIa inhibitors, in particular of abciximab, in patients with STEMI in whom primary angioplasty is planned should not be discouraged because of the potential bleeding risk in case of emergency CABG.

[Acute coronary syndrome (ACS) with elevated ST segment: consensus strategy for early reperfusion. The Public Enterprise for Health Emergencies and the ARIAM Project Andalusia]

The two pillars of the appropriate management of patients with ST-elevation myocardial infarction (STEMI) are immediate access to defibrillation and early reperfusion. The Public Enterprise for Health Emergencies (EPES) and the Andalusian ARIAM (Analysis of the Delay in the Treatment of Acute Myocardial Infarction) Project aim to implement a common basic strategy that can be adapted to local situations in order to facilitate decision making about the treatment of these patients.

CONTEXT

The Autonomous Community of Andalusia.

PERIOD

March-May 2006.

PARTICIPANTS

Professionals that attend patients with STEMI: physicians in the EPES' work group on cardiological processes, emergency department physicians, and physicians working in the intensive care units in the hospitals of the public healthcare system of Andalusia.

APPROACH

Levels of evidence. The levels of evidence laid out in the 2004 ACC/AHA Clinical Practice Guidelines. REACHING A CONSENSUS: A meeting was held to discuss the aspects to be included in the document. A working document was drafted and distributed to the participants via email. The final consensus document was drafted at another meeting.

CONCLUSIONS

The consensus document establishes the following priorities: 1. To apply the set of general measures recommended for the care of STEMI patients strictly and appropriately 2. To foster the use of early reperfusion in as many patients as possible, promoting the extension of fibrinolysis outside of hospitals and referral to a center with facilities for primary percutaneous coronary intervention. 3. To monitor and evaluate the management of these patients, with special attention placed on outcome and safety.

Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options

There are an estimated 500,000 ST-segment elevation myocardial infarction (STEMI) events in the U.S. annually. Despite improvements in care, up to one-third of patients presenting with STEMI within 12 h of symptom onset still receive no reperfusion therapy acutely. Clinical studies indicate that speed of reperfusion after infarct onset may be more important than whether pharmacologic or mechanical intervention is used. Primary percutaneous coronary intervention (PCI), when performed rapidly at high-volume centers, generally has superior efficacy to fibrinolysis, although fibrinolysis may be more suitable for many patients as an initial reperfusion strategy. Because up to 70% of STEMI patients present to hospitals without on-site PCI facilities, and prolonged door-to-balloon times due to inevitable transport delays commonly limit the benefit of PCI, the continued role and importance of the prompt, early use of fibrinolytic therapy may be underappreciated. Logistical complexities such as triage or transportation delays must be considered when a reperfusion strategy is selected, because prompt fibrinolysis may achieve greater benefit, especially if the fibrinolytic-to-PCI time delay associated with transfer exceeds approximately 1 h. Selection of a fibrinolytic requires consideration of several factors, including ease of dosing and combination with adjunctive therapies. Careful attention to these variables is critical to ensuring safe and rapid reperfusion, particularly in the prehospital setting. The emerging modality of pharmacoinvasive therapy, although controversial, seeks to combine the benefits of mechanical and pharmacologic reperfusion. Results from ongoing clinical trials will provide guidance regarding the utility of this strategy.

Reperfusion strategies for ST-elevation myocardial infarction

Management of ST-elevation myocardial infarction requires rapid, sustained and early restoration of flow in the infarct-related artery to minimize myocardial damage and to improve clinical outcomes. Primary percutaneous coronary intervention (PCI) is the preferred therapy but is limited by restricted availability and delays in implementation. Fibrinolytic administration is widely available but is limited by its failure to achieve Thrombolysis in Myocardial Infarction grade 3 flow in many patients, re-infarction, and intracranial hemorrhage. A combination approach to reperfusion--facilitated PCI--involves the administration of a pharmacologic agent to improve reperfusion with PCI. The evidence supporting facilitated PCI varies according to the pharmacologic regimen at this time.

New trials and therapies for acute myocardial infarction

Acute coronary syndromes (ACSs), which include the clinical entities of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), account for more than 1.5 million hospital admissions annually in the United States alone. Approximately 1 million of these admissions are classified as UA/NSTEMI and approximately 500,000 are STEMI. Because of the overwhelming number of studies on ACSs over the past several years, this article focuses on new trials and therapies for treating patients diagnosed with STEMI.

Time to reperfusion in acute myocardial infarction. It is time to reduce it!

BACKGROUND AND OBJECTIVES

Mortality from ST-segment elevation myocardial infarction remains high, with most deaths occurring before hospital admission. Despite effective pre- and in-hospital reperfusion strategies becoming standard over the past 2 decades, time-to-admission and time-to-treatment remain prolonged. We reviewed temporal trends in these times in published clinical trials.

METHODS

All major randomized clinical trials reporting on reperfusion strategies for acute myocardial infarction published between 1993 and 2003 were evaluated. Strategies included pre- and in-hospital thrombolysis, primary percutaneous coronary intervention (pPCI) with or without transfer, and "facilitated" PCI. We generated overall estimates of time-to-admission, time-to-treatment, door-to-balloon (DTB), and door-to-needle (DTN) times and evaluated temporal trends in the length of time-to-admission and time-to-treatment.

RESULTS

In studies that evaluated only in-hospital thrombolysis, the time-to-admission was 149 +/- 45 minutes; the mean time-to-treatment was 181 +/- 29 minutes. In studies that considered only in-hospital pPCI (without transfer), the mean time-to-admission was 153 +/- 41 minutes; the mean time-to-treatment was 234 +/- 43 minutes. In studies that compared in-hospital pPCI with in-hospital thrombolytic therapy, the mean time-to-admission was 155 +/- 47 and 150 +/- 48 minutes, respectively. The DTN time was 65 +/- 10 minutes, whereas DTB time was 81 +/- 39 minutes. In other trials evaluating in-hospital thrombolysis and pPCI with transfer to a referral center, the time-to-admission in subjects treated with thrombolysis (n = 1345) was 127 +/- 32 minutes vs 131 +/- 36 minutes for pPCI (n = 1528). For in-hospital thrombolysis, time-to-treatment was 151 +/- 23 minutes vs 203 +/- 15 minutes for pPCI patients with transfer. The DTN time in the thrombolysis group was 44 +/- 28 minutes as compared with DTB time of 78 +/- 38 minutes in the pPCI group. Throughout the last decade, time-to-admission decreased significantly (P = .02) but time-to-treatment remained unchanged (P = .38) for patients undergoing thrombolysis. In the pPCI arm, time-to-admission remained unchanged (P = .11) but a insignificant trend toward reduction was demonstrated in time-to-treatment (P = .11).

CONCLUSION

Time-to-admission and time-to-treatment for ST-segment elevation myocardial infarction are still prolonged. Resources should be directed to early recognition of the acute myocardial infarction, improved utilization of emergency services for transportation, and prehospital diagnosis and triaging. Ambulances equipped with wireless capability to transmit electrocardiograms to the on-call cardiologist seem to be promising tools to achieve earlier diagnosis and triaging with high diagnostic sensitivity and specificity.

Randomized Early Versus Late Abciximab in Acute Myocardial Infarction Treated With Primary Coronary Intervention (RELAx-AMI Trial)

OBJECTIVES

This prospective randomized trial evaluates the impact of early abciximab administration on angiographic and left ventricular function parameters.

BACKGROUND

Glycoprotein IIb/IIIa inhibitors improve myocardial reperfusion in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI), but optimal timing of administration remains unclear.

METHODS

Two-hundred ten consecutive patients with first AMI undergoing primary PCI were randomized to abciximab administration either in the emergency room (early group: 105 patients) or in the catheterization laboratory, after coronary angiography (late group: 105 patients). Primary end points were initial Thrombolysis In Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count (cTFC), and myocardial blush grade (MBG), as well as left ventricular function recovery as assessed by serial echocardiographic evaluations.

RESULTS

Angiographic pre-PCI analysis showed a significantly better initial TIMI flow grade 3 (24% vs. 10%; p = 0.01), cTFC (78 +/- 30 frames vs. 92 +/- 21 frames; p = 0.001), and MBG 2 or 3 (15% vs. 6%; p = 0.02) favoring the early group. Consistently, post-PCI tissue perfusion parameters were significantly improved in the early group, as assessed by 60-min ST-segment reduction > or =70% (50% vs. 35%; p = 0.03) and MBG 2 or 3 (79% vs. 58%; p = 0.001). Left ventricular function recovery at 1 month was significantly greater in the early group (mean gain ejection fraction 8 +/- 7% vs. 6 +/- 7%, p = 0.02; mean gain wall motion score index 0.4 +/- 0.3 vs. 0.3 +/- 0.3, p = 0.03).

CONCLUSIONS

In patients with AMI treated with primary PCI, early abciximab administration improves pre-PCI angiographic findings, post-PCI tissue perfusion, and 1-month left ventricular function recovery, possibly by starting early recanalization of the infarct-related artery.

Reperfusion strategies in the emergency treatment of ST-segment elevation myocardial infarction

Prompt restoration of blood flow is the primary treatment goal in ST-segment elevation myocardial infarction to optimize clinical outcomes. The ED plays a critical role in rapid triage, diagnosis, and management of ST-elevation myocardial infarction, and in the decision about which of the 2 recommended reperfusion options, that is, pharmacologic and mechanical (catheter-based) strategies, to undertake. Guidelines recommend percutaneous coronary intervention (PCI) if the medical contact-to-balloon time can be kept under 90 minutes, and timely administration of fibrinolytics if greater than 90 minutes. Most US hospitals do not have PCI facilities, which means the decision becomes whether to treat with a fibrinolytic agent, transfer, or both, followed by PCI if needed. Whichever reperfusion approach is used, successful treatment depends on the ED having an integrated and efficient protocol that is followed with haste. Protocols should be regularly reviewed to accommodate changes in clinical practice arising from ongoing clinical trials.

[Acute myocardial infarction: what is new?]

Current recommendations on the management of acute myocardial infarction and the use of thrombolysis are reviewed.

Evolving management of ST-segment elevation myocardial infarction: update on recent data

Significant recent advances have been made in strategies for managing ST-segment elevation myocardial infarction (STEMI). Based on new findings, the American College of Cardiology (ACC) and the American Heart Association (AHA) have updated their guidelines for acute myocardial infarction (MI) with newer recommendations for STEMI management. Many of these recommendations focus on antithrombotic agents, with a movement toward lower doses of long-term aspirin and lower doses of unfractionated heparin (UFH). Studies have also been completed on the use of enoxaparin and fondaparinux as potential alternatives to heparin, and clinical trial data support the early use of glycoprotein IIb/IIIa inhibitors (along with aspirin, UFH, and clopidogrel) in patients undergoing primary percutaneous coronary intervention for acute STEMI. Clopidogrel has also been shown to improve angiographic and clinical outcomes in patients with STEMI who are undergoing thrombolysis or being treated medically. The new ACC/AHA recommendations support clopidogrel pretreatment and long-term therapy.

ST-segment recovery and prognosis in patients with ST-elevation myocardial infarction reperfused by prehospital combination fibrinolysis, prehospital initiated facilitated percutaneous coronary intervention, or primary percutaneous coronary intervention

Complete ST-segment recovery (STR) is associated with favorable prognosis in ST-elevation myocardial infarction (STEMI). The optimal reperfusion strategy in patients presenting soon after symptom onset is still a matter of debate. STR for patients treated by prehospital combination fibrinolysis or prehospital initiated facilitated percutaneous coronary intervention (PCI) compared with primary PCI has not been assessed. In the Leipzig Prehospital Fibrinolysis Study, patients with STEMI (symptoms <6 hours) were randomized to prehospital combination fibrinolysis (1/2 dose reteplase + abciximab; n = 82, group A) or prehospital initiated facilitated PCI (n = 82, group B). Further, a control group of patients with primary PCI (n = 136, group C) was prospectively assessed. STR at 90 minutes was analyzed by blinded observers as percent resolution. Categorization was performed as complete resolution (>70%), intermediate resolution (70% to 30%), or no resolution (<30%). The percentage of patients with complete STR was highest in group B with 80% versus 52% in group A and 52% in group C (p <0.001, B vs A and C, p = NS; A vs C). Complete STR resulted in lower event rates for the combined clinical end point of death, myocardial reinfarction, and stroke compared with intermediate and no STR in groups A (complete 9.8%, intermediate 23.8%, no STR 36.8%, p = 0.04), B (7.7%, 18.2%, and 50.0%, p = 0.01), and C (8.6%, 18.4%, and 42.9%, p <0.001). In conclusion, prehospital initiated facilitated PCI results in the highest percentage of complete STR compared with prehospital combination fibrinolysis or primary PCI. In addition, STR has been confirmed to predict prognosis in timely optimized reperfusion strategies.

Facilitated Percutaneous Coronary Intervention

The goal of the initial treatment for ST-segment elevation myocardial infarction is rapid and effective reperfusion. Randomized trials have demonstrated that primary angioplasty is preferred over thrombolysis if done in a timely manner and by an experienced team. However, due to many factors, performance of primary angioplasty within the goal of 90 min is often not possible. A combined strategy of immediate thrombolysis in the emergency room or in the ambulance followed by angioplasty theoretically could provide early reperfusion with subsequent angioplasty to insure complete reperfusion. Over 17 clinical trials have been reported. Compared with thrombolysis, facilitated angioplasty in the most recent trials has been shown to have a more favorable long-term outcome. Trials comparing facilitated angioplasty with full- or half-dose thrombolysis versus primary angioplasty have been far less favorable with the largest trial to date, the ASSENT (Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention)-4 trial, demonstrating a worse outcome in the primary end point of death, congestive heart failure, or shock at 90 days. Pending the results of the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial, current data suggest that facilitated angioplasty does not offer any advantage over primary angioplasty and may be harmful.

Update and rationale for ongoing acute myocardial infarction trials: combination therapy, facilitation, and myocardial preservation

Advancements in the treatment of myocardial infarction such as coronary care units, patient education, improved emergency response systems, and reperfusion therapy have reduced mortality. However, in an effort to further reduce the present rate by improving patency rates and microcirculatory perfusion, by better preserving myocardium, and/or treating shock more effectively, more research is under way to improve strategies now in place and to develop new, more effective ways to treat these patients.

Immediate angioplasty after thrombolysis: a systematic review

BACKGROUND

The role of immediate transfer for percutaneous coronary intervention (PCI) after thrombolysis for ST-segment elevation myocardial infarction remains controversial. We performed a systematic review of the related literature to determine whether thrombolysis followed by transfer for immediate or early PCI is safe, feasible and superior to conservative management.

METHODS

A systematic literature search of MEDLINE, EMBASE, the Cochrane Database for Systematic Reviews and Cochrane Central Register of Controlled Trials, and the American Heart Association EndNote 7 Master Library databases, was performed to 2004 for relevant published studies. The level of evidence and the quality of the study design and methods were rated by 2 reviewers according to a standardized classification. A quantitative meta-analysis was performed to assess the effect at 6-12 months on mortality of immediate or early PCI after thrombolysis.

RESULTS

We found 13 articles that were supportive of immediate or early PCI after thrombolysis and 16 that were neutral or provided evidence opposing it. The largest randomized trials and meta-analyses showed no benefit of routine PCI immediately or shortly after thrombolysis. The studies that were supportive were generally more recent and more frequently involved coronary stents. One large trial supported early PCI after thrombolysis for patients with myocardial infarction complicated by cardiogenic shock. Overall, the difference in mortality rates between the invasive strategy and conservative care was nonsignificant. The 3 stent-era trials showed a significantly lower mortality among patients randomly assigned to the invasive strategy (5.8% v. 10.0%, odds ratio 0.55, 95% confidence interval 0.32-0.92). Analysis of variance found a significant difference in treatment effect between stent-era and pre-stent-era trials.

INTERPRETATION

At present, there is inadequate evidence to recommend routine transfer of patients for immediate or early PCI after successful thrombolysis. Results of recent trials using contemporary PCI techniques, including coronary stents, appear more favourable but need to be confirmed in large randomized trials, which are currently in progress. Transfer for immediate PCI is recommended for patients with cardiogenic shock, hemodynamic instability or persistent ischemic symptoms after thrombolysis.

Early abciximab administration in acute myocardial infarction treated with primary coronary intervention

BACKGROUND

Glycoprotein IIb/IIIa inhibitors improve myocardial reperfusion and clinical outcomes of patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI), but optimal timing of administration remains unclear. In this prospective randomized trial, we evaluated the impact of early abciximab administration on angiographic findings, myocardial salvage and left ventricular function.

METHODS AND RESULTS

Fifty-five consecutive patients with first AMI, undergoing primary PCI, were randomized to abciximab administration either in the emergency room (early group: 27 patients) or in the catheterization laboratory after coronary angiography (late group: 28 patients). The primary outcome measures were initial Thrombolysis In Myocardial Infraction (TIMI) grade flow, corrected TIMI frame count and myocardial blush grade as well as salvage index and left ventricular function recovery as assessed by serial scintigraphic scans performed at admission, and 7 days and 1 month after PCI. Angiographic analysis showed a significant difference in initial TIMI grade 3 flow, corrected TIMI frame count and myocardial blush grade favouring early group. Moreover, salvage index and left ventricular function recovery were significantly greater in the early group (P=0.007; and P=0.043, respectively).

CONCLUSIONS

In patients with AMI, treated with primary PCI, early abciximab administration improves myocardial salvage and left ventricular function recovery probably by starting early recanalization of the infarct-related artery.

Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial

BACKGROUND

Primary percutaneous coronary intervention (PCI) is more effective than fibrinolytic therapy for ST-segment elevation acute myocardial infarction (STEMI), but time to intervention can be considerable. Our aim was to investigate whether the administration of full-dose tenecteplase before a delayed PCI could mitigate the negative effect of this delay.

METHODS

We did a randomised study in which we assigned patients with STEMI of less than 6 h duration (scheduled to undergo primary PCI with an anticipated delay of 1-3 h) to standard PCI (n=838) or PCI preceded by administration of full-dose tenecteplase (n=829). All patients received aspirin and a bolus, without an infusion, of unfractionated heparin. Our primary endpoint was death or congestive heart failure or shock within 90 days. Analyses were by intention to treat. This study is registered with , number NCT00168792.

FINDINGS

We planned to enroll 4000 patients, but early cessation of enrollment was recommended by the data and safety monitoring board because of a higher in-hospital mortality in the facilitated than in the standard PCI group (6% [43 of 664] vs 3% [22 of 656], p=0.0105). Of those enrolled, six were lost to follow-up in the facilitated PCI group and seven in the other group. Median time from randomisation to first balloon inflation was similar in both groups. The median time from bolus tenecteplase to first balloon inflation was 104 min. We noted the primary endpoint in 19% (151 of 810) of patients assigned facilitated PCI versus 13% (110 of 819) of those randomised to primary PCI (relative risk 1.39, 95% CI 1.11-1.74; p=0.0045). During hospital stay, significantly more strokes (1.8% [15 of 829] vs 0, p<0.0001), but not major non-cerebral bleeding complications (6% [46 of 829] vs 4% [37 of 838], p=0.3118), were reported in patients assigned facilitated rather than standard PCI. We also noted more ischaemic cardiac complications, such as reinfarction (6% [49 of 805] vs 4% [30 of 820], p=0.0279) or repeat target vessel revascularisation (7% [53 of 805] vs 3% [28 of 818], p=0.0041) within 90 days in this study group.

INTERPRETATION

A strategy of full-dose tenecteplase with antithrombotic co-therapy, as used in this study and preceding PCI by 1-3 h, was associated with more major adverse events than PCI alone in STEMI and cannot be recommended.

Assessment of early administration of abciximab in acute ST-segment elevation myocardial infarction in the emergency room

OBJECTIVE

Abciximab, a platelet glycoprotein IIb/IIIa inhibitor, administered in conjunction with primary coronary stenting, improves the outcome of acute myocardial infarction, and the earlier it is administered, the greater the improvement. We sought to assess the feasibility of early administration of abciximab in the emergency room (ER) before primary coronary stenting and compare our results with those of a group of patients treated in the prehospital (ambulance) phase.

METHODS

Data and outcome of patients with acute ST-segment elevation myocardial infarction who received abciximab (0.25 mg x kg(-1) then 0.125 mg x kg(-1) x h(-1)) in the ER before primary coronary stenting were compared with those of patients who received abciximab in the prehospital phase.

RESULTS

Characteristics of the group treated in the ER did not differ significantly from those of patients treated before arrival at the hospital, except for prevalence of diabetes (22 versus 5%, p<0.05) and administration of analgesic to control chest pain (22 versus 65%, p<0.05). Nor did the median time between onset of pain and abciximab administration differ significantly different (120 versus 160 min, NS). In contrast, the median delay between the beginning of abciximab administration and insertion of the cardiac catheter was significantly shorter in the ER group (35 versus 55 min, p<0.05). There were no significant differences between groups in TIMI flow grade before or after revascularization, specific revascularization performed, or outcome.

CONCLUSION

Our study provides some evidence that early administration of abciximab in the ER is safe, feasible, and justified by the delay required for coronary revascularization.

Implementation of reperfusion therapy in acute myocardial infarction. A policy statement from the European Society of Cardiology

Reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) is the most important component of treatment, as it strongly influences short- and long-term patient outcome. The main objective of healthcare providers should be to achieve at least 75% of reperfusion therapy applied to patients suffering from STEMI in a timely manner, and preferably within the first 3 h after onset of symptoms. Establishing networks of reperfusion at regional and national level, implying close collaboration between all the actors involved in reperfusion therapy, namely hospitals, departments of cardiology, PCI centres, emergency medical systems (EMS), (para)medically staffed ambulances, private cardiologists, primary care physicians, etc., is a key issue. All forms of reperfusion, depending on local facilities, need to be available to patients. Protocols must be written and agreed for the strategy of reperfusion to be applied within a network. Early diagnosis of STEMI is essential and is best achieved by rapid ECG recording and interpretation at first medical contact, wherever this contact takes place (hospital or ambulance). Tele-transmission of ECG for immediate interpretation by experienced cardiologists is an alternative. Primary PCI is the preferred reperfusion option if it can be performed by experienced staff within 90 min after first medical contact. Thrombolytic treatment, administered if possible in the pre-hospital setting, is a valid option if PCI cannot be performed in a timely manner, particularly within the first 3 h following onset of symptoms. Thrombolysis is not the end of the reperfusion therapy. Rescue PCI must be performed in the case of thrombolysis failure. Next-day PCI after successful thrombolysis has been proven efficacious. Quality control is important for monitoring the efficacy of networks of reperfusion. All elements that influence time to reperfusion must be taken into account, particularly transfer delays, in-hospital delays, and door-to-balloon or door-to-needle times. The rate of reperfusion achieved must also be taken into consideration. Professional organizations such as the European Society of Cardiology (ESC) have the responsibility to impart this message to the cardiology community, and inform politicians and health authorities about the best possible strategy to achieve reperfusion therapy.

Coronary interventions and their impact on post myocardial infarction survival

Rapid reestablishment of infarct vessel patency and microvascular flow provides the best opportunity for minimizing mortality in the patient post myocardial infarction (MI). Early infarct artery patency can be restored by thrombolysis, primary angioplasty, or facilitated percutaneous coronary intervention (PCI). In comparative studies, primary angioplasty offers a greater mortality benefit than thrombolysis in patients with acute MI. Short-term rates of mortality and stroke were significantly lower in patients receiving primary angioplasty compared with thrombolysis, as was the risk of nonfatal reinfarction. The timing of reperfusion therapy after symptom onset affects outcomes. Patients presenting >3 h after symptom onset are likely to benefit more from PCI than from thrombolysis. Nevertheless, PCI should be performed as soon as possible for optimal results. If PCI is to be delayed, then immediate thrombolysis is likely to be as effective as PCI. Registry data indicate that reperfusion for acute MI is currently underused, with different techniques frequently misapplied. Outcomes tend to be better at centers that perform a high volume of reperfusion procedures, partly due to shorter treatment delays. Facilitated PCI combines fibrinolytic therapy with angioplasty. It is designed to promote very early patency in those who respond to drug therapy, with very high final patency rates assured by angioplasty. Clinical trials have generally found facilitated PCI to be more efficacious than thrombolysis alone. Rescue PCI in cases of failed fibrinolysis is associated with a modest mortality benefit compared with conservative treatment. Myocardial injury following reperfusion after ischemia can limit the benefits of PCI and fibrinolysis; however, strategies for minimizing reperfusion injury have not yet shown clinical efficacy.

Early versus periprocedural administration of abciximab for primary angioplasty: a pooled analysis of 6 studies

BACKGROUND

The 2004 ACC/AHA guidelines on ST-elevation myocardial infarction state that it is reasonable to start treatment with abciximab as early as possible before primary percutaneous coronary intervention (PCI). We investigated the potential benefit of early use of abciximab by pooling data from all the available studies.

METHODS

Six prospective studies were identified that had allocated 260 patients to receive early abciximab (either prehospital or soon after the patient arrived in hospital) and 342 to receive late abciximab (at the time of PCI).

RESULTS

TIMI flow grade 2 or 3 was present in 42% of the early group compared with 29% in the late group (P = .001). After PCI, 59% of patients in the early group showed ST-resolution >or = 70%, compared with 41% in the late group (P = .003). The composite clinical outcomes death, new myocardial infarction, or repeat target vessel revascularization at 30 days occurred in 7.3% of the early group compared with 9.7% in the late group (odds ratio 0.73, 95% CI 0.41-1.32) and death alone occurred in 2.7% versus 4.7%, respectively (odds ratio 0.56, 95% CI 0.23-1.39).

CONCLUSIONS

Early administration of abciximab improves epicardial patency (TIMI flow) before PCI and results in better myocardial tissue perfusion (ST-resolution) after the procedure. The promising effects on clinical outcomes need to be tested in larger studies.

Acute reperfusion therapy in acute myocardial infarction

The ECG classification of acute myocardial infarctions has had a profound influence on the treatment of patients with AMI. Deciding whether a patient has ST-segment elevations or a new left bundle branch block or neither of these findings on ECG launches the treating physician down two different treatment pathways: patients with ST-elevation MI need to be assessed for immediate re-perfusion therapy, whereas patients with non-ST-elevation MI are best treated with aggressive medical management without acute reperfusion.