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Shen M, Wang J, Li D, Zhou X, Guo Y, Zhang W, Guo Y, Wang J, Liu J, Zhao G, Zhao S, Tian J. IntraCoronary Artery Retrograde Thrombolysis vs. Thrombus Aspiration in ST-Segment Elevation Myocardial Infarction: Study Protocol for a Randomized Controlled Trial. Front Cardiovasc Med 2022; 9:928695. [PMID: 36186981 PMCID: PMC9520188 DOI: 10.3389/fcvm.2022.928695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022] Open
Abstract
Background Type 2 diabetes (T2DM) is a major risk factor for myocardial infarction. Thrombus aspiration was considered a good way to deal with coronary thrombus in the treatment of acute myocardial infarction. However, recent studies have found that routine thrombus aspiration is not beneficial. This study is designed to investigate whether intracoronary artery retrograde thrombolysis (ICART) is more effective than thrombus aspiration or percutaneous transluminal coronary angioplasty (PTCA) in improving myocardial perfusion in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Methods/Design IntraCoronary Artery Retrograde Thrombolysis (ICART) vs. thrombus aspiration or PTCA in STEMI trial is a single-center, prospective, randomized open-label trial with blinded evaluation of endpoints. A total of 286 patients with STEMI undergoing PPCI are randomly assigned to two groups: ICART and thrombus aspiration or PTCA. The primary endpoint is the incidence of >70% ST-segment elevation resolution. Secondary outcomes include distal embolization, myocardial blush grade, thrombolysis in myocardial infarction (TIMI) flow grade, and in-hospital bleeding. Discussion The ICART trial is the first randomized clinical trial (RCT) to date to verify the effect of ICART vs. thrombus aspiration or PTCA on myocardial perfusion in patients with STEMI undergoing PPCI. Clinical Trial Registration [https://www.chictr.org.cn/], identifier [ChiCTR1900023849].
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Affiliation(s)
- Mingzhi Shen
- Department of Cardiology, Hainan Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jihang Wang
- Department of Cardiology, Hainan Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Sanya, China
| | - Dongyun Li
- The First Department of Health Care, Second Medical Center, PLA General Hospital, Beijing, China
| | - Xinger Zhou
- Department of Cardiology, Hainan Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yuting Guo
- Department of Cardiology, Hainan Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Wei Zhang
- Department of Cardiology, Second Medical Center, PLA General Hospital, Beijing, China
| | - Yi Guo
- Department of Cardiology, Hainan Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Sanya, China
| | - Jian Wang
- Department of Cardiology, Hainan Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Sanya, China
| | - Jie Liu
- Department of Critical Medicine, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Guang Zhao
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shihao Zhao
- Department of Cardiology, Hainan Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Sanya, China
- *Correspondence: Jinwen Tian,
| | - Jinwen Tian
- Department of Cardiology, Hainan Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Shihao Zhao,
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2
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Fabris E, Hermanides R, Roolvink V, Ibanez B, Ottervanger JP, Pizarro G, van Royen N, Mateos-Rodriguez A, Dambrink JH, Albarran A, Fernández-Avilés F, Botas J, Remkes W, Hernandez-Jaras V, Kedhi E, Zamorano J, Alfonso F, García-Lledó A, van Leeuwen M, Nijveldt R, Postma S, Kolkman E, Gosselink M, de Smet B, Rasoul S, Lipsic E, Piek JJ, Fuster V, van 't Hof AW. Beta-blocker effect on ST-segment: a prespecified analysis of the EARLY-BAMI randomised trial. Open Heart 2021; 7:openhrt-2020-001316. [PMID: 33318150 PMCID: PMC7737101 DOI: 10.1136/openhrt-2020-001316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/06/2020] [Accepted: 10/23/2020] [Indexed: 11/13/2022] Open
Abstract
Objective The effect of early intravenous (IV) beta-blockers (BBs) administration in patients undergoing primary percutaneous coronary intervention (pPCI) on ST-segment deviation is unknown. We undertook a prespecified secondary analysis of the Early Beta-blocker Administration before primary PCI in patients with
ST-elevation Myocardial Infarction (EARLY-BAMI) trial to investigate the effect of early IV BB on ST-segment deviation. Methods The EARLY-BAMI trial randomised patients with ST-elevation myocardial infarction (STEMI) to IV metoprolol (2×5 mg bolus) or matched placebo before pPCI. The prespecified outcome, evaluated by an independent core laboratory blinded to study treatment, was the residual ST-segment deviation 1 hour after pPCI (ie, the percentage of patients with >3 mm cumulative ST deviation at 1 hour after pPCI). Results An ECG for the evaluation of residual ST-segment deviation 1 hour after pPCI was available in 442 out of 683 randomised patients. The BB group had a lower heart rate after pPCI compared with placebo (71.2±13.2 vs 74.3±13.6, p=0.016); however, no differences were noted in the percentages of patients with >3 mm cumulative ST deviation at 1 hour after pPCI (58.6% vs 54.1%, p=0.38, in BB vs placebo, respectively) neither a significant difference was found for the percentages of patients in each of the four prespecified groups (normalised ST-segment; 1–3 mm; 4–6 mm;>6 mm residual ST-deviation). Conclusions In patients with STEMI, who were being transported for primary PCI, early IV BB administration did not significantly affect ST-segment deviation after pPCI compared with placebo. The neutral result of early IV BB administration on an early marker of pharmacological effect is consistent with the absence of subsequent improvement of clinical outcomes.
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Affiliation(s)
- Enrico Fabris
- Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands .,Cardiovascular Department, University of Trieste, Trieste, Italy
| | | | - Vincent Roolvink
- Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,IIS-Fundación Jiménez Díaz, Madrid, Spain.,CIBERCV, Madrid, Spain
| | | | - Gonzalo Pizarro
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,CIBERCV, Madrid, Spain.,Hospital Ruber Juan Bravo UEM, Madrid, Spain
| | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Alonso Mateos-Rodriguez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Facultad de Medicina. Universidad Francisco de Vitoria, Madrid, Spain
| | - Jan Henk Dambrink
- Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands
| | - Agustin Albarran
- Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Francisco Fernández-Avilés
- CIBERCV, Madrid, Spain.,Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain.,ISCIII, Madrid, Spain
| | - Javier Botas
- Servicio de Cardiologia, Hospital Universitario Fundacion Alcorcon, Madrid, Spain
| | | | | | - Elvin Kedhi
- Erasmus Hospital, Université libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Jose Zamorano
- CIBERCV, Madrid, Spain.,University Hopsital Ramon y Cajal, Madrid, Spain
| | - Fernando Alfonso
- Department of Cardiology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Alberto García-Lledó
- Department of Cardiology, Hospital Príncipe de Asturias, Alcala de Henares, Madrid, Spain
| | | | | | | | | | - Marcel Gosselink
- Department of Cardiology, Isala Hartcentrum, Zwolle, The Netherlands
| | - Bart de Smet
- Department of Cardiology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Saman Rasoul
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Zuyderland Medical Centre Heerlen, Heerlen, Limburg, The Netherlands
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Mount Sinai School Medicine, New York, New York, USA
| | - Arnoud Wj van 't Hof
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Zuyderland Medical Centre Heerlen, Heerlen, Limburg, The Netherlands
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3
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Grimm K, Twerenbold R, Abaecherli R, Boeddinghaus J, Nestelberger T, Koechlin L, Troester V, Bourtzou A, Keller DI, Geigy N, Kozhuharov N, Wussler D, Wildi K, Hillinger P, Rubini Giménez M, Strebel I, Badertscher P, Puelacher C, du Fay de Lavallaz J, Osswald L, Morawiec B, Kawecki D, Miró Ò, Kühne M, Reichlin T, Mueller C. Diagnostic and prognostic value of ST-segment deviation scores in suspected acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:857-868. [PMID: 31976746 DOI: 10.1177/2048872619853579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recent advances in digital electrocardiography technology allow evaluating ST-segment deviations in all 12 leads as quantitative variables and calculating summed ST-segment deviation scores. The diagnostic and prognostic utility of summed ST-segment deviation scores is largely unknown. METHODS We aimed to explore the diagnostic and prognostic utility of the conventional and the modified ST-segment deviation score (Better Analysis of ST-segment Elevations and Depressions in a 12- Lead-ECG-Score (BASEL-Score): sum of elevations in the augmented voltage right - lead (aVR) plus absolute, unsigned ST-segment depressions in the remaining leads) in patients presenting with suspected non-ST-segment elevation myocardial infarction. The diagnostic endpoint was non-ST-segment elevation myocardial infarction, adjudicated by two independent cardiologists. Prognostic endpoint was mortality during two-year follow up. RESULTS Among 1330 patients, non-ST-segment elevation myocardial infarction was present in 200 (15%) patients. Diagnostic accuracy for non-ST-segment elevation myocardial infarction as quantified by the area under the receiver-operating-characteristics curve was significantly higher for the BASEL-Score (0.73; 95% confidence interval 0.69-0.77) as compared to the conventional ST-segment deviation score (0.53; 95% confidence interval 0.49-0.57, p<0.001). The BASEL-Score provided additional independent diagnostic value to dichotomous electrocardiogram variables (ST-segment depression, T-inversion, both p<0.001) and to high-sensitivity cardiac troponin (p<0.001) as well as clinical judgment at 90 min (p<0.001). Similarly, only the BASEL-Score proved to be an independent predictor of two year mortality. CONCLUSIONS The modified ST-segment deviation score BASEL-Score focusing on ST-segment elevation in aVR and ST-segment depressions in the remaining leads provides incremental diagnostic and prognostic information.
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Affiliation(s)
- Karin Grimm
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Roger Abaecherli
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Institute for Medical Engineering, Lucerne University of Applied Sciences and Arts, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Luca Koechlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Valentina Troester
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Anna Bourtzou
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Baselland, Switzerland
| | - Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Petra Hillinger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Maria Rubini Giménez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Servicio de Urgencias y Pneumologia, Hospital del Mar - Institut Municipal d'Investigació Mèdica, Spain.,Leipzig Heart Center, Leipzig, Germany
| | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Internal Medicine, University Hospital Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
| | - Luca Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Beata Morawiec
- 2nd Department of Cardiology, Zabrze, Medical University of Silesia in Katowice, Poland
| | - Damian Kawecki
- 2nd Department of Cardiology, Zabrze, Medical University of Silesia in Katowice, Poland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Michael Kühne
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy.,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Global Research on acute conditions Team (GREAT Network), Italy
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4
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Guo Z, Yang X. Does pre-angiography Total ST-segment resolution reliably predict spontaneous reperfusion of the infarct-related artery in patients with acute myocardial infarction? BMC Cardiovasc Disord 2019; 19:264. [PMID: 31771514 PMCID: PMC6880478 DOI: 10.1186/s12872-019-1229-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 10/21/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND ST resolution (STR) after AMI is a non-invasive indicator of IRA reperfusion. We investigated whether pre-angiography STR predicted spontaneous IRA reperfusion in STEMI patients. METHOD Patients with STEMI undergoing primary PCI were recruited. Standard 12-lead ECG tracings were recorded at first medical contact, immediately prior to arterial puncture and 60 min after PCI. STR was classified as total (≥70%; group I), partial (≥30 and < 70%; group II) or none (< 30%; group III). Patients were followed up for 1-year. RESULTS The final analysis included 349 patients (n = 77, 160 and 112 for groups I, II and III, respectively). Compared with groups I/II, pre-procedural TIMI flow in group III was less frequently grades 2 or 3 (P < 0.001). Pre-PCI STR ≥70% was an independent predictor of pre-PCI TIMI-3 flow (OR: 2.8; P < 0.001). Pre-PCI STR < 30% was independently associated with pre-PCI TIMI flow 0-2 (OR: 3.1; P < 0.001). STR = 35.55% seems to be an optimal cut off for pre-procedural TIMI-3 flow prediction with sensitivity 0.943, specificity 0.456, Youden index 0.399, P = 0.027. STR prior to PCI was inversely correlated with 1-year combined CV events rate. STR > 70% may predict a better clinical outcome. CONCLUSIONS Assessment of STR could potentially be used to stratify risk in patients with STEMI before PCI.
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Affiliation(s)
- Zongsheng Guo
- Heart Center, Beijing Chaoyang Hospital, No. 8 workers' stadium south road, Chaoyang District, Beijing, 100027, China
| | - Xinchun Yang
- Heart Center, Beijing Chaoyang Hospital, No. 8 workers' stadium south road, Chaoyang District, Beijing, 100027, China.
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5
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Verdoia M, Schaffer A, Cassetti E, Di Giovine G, Marino P, Suryapranata H, De Luca G. Absolute eosinophils count and the extent of coronary artery disease: a single centre cohort study. J Thromb Thrombolysis 2016; 39:459-66. [PMID: 25079972 DOI: 10.1007/s11239-014-1120-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Leukocytes have been involved in the pathogenesis of atherosclerosis, and recent attention has been raised on eosinophils, that have been claimed for a wide number of cardiovascular pathologies, affecting endocardium, myocardium and vascular walls. However, few data have been reported so far on the relationship between absolute eosinophils count (AEC) and the prevalence and extent of coronary artery disease (CAD), that was the aim of present study. Consecutive patients undergoing non-urgent coronary angiography were included. Haematological parameters were measured at admission. Significant CAD was defined as at least 1 vessel stenosis >50 %, while severe CAD as left main and/or trivessel disease, as evaluated by Quantitative Coronary Angiography. Our population is represented by 3,742 patients, divided according to tertiles values of AEC (≤0.1; 0.1-0.2; >0.2 × 10(3)/µl). Higher eosinophils values were significantly associated to male gender, main established cardiovascular risk factors, previous percutaneous or surgical coronary revascularization, antihypertensive and antiplatelet therapy at admission but inversely with acute presentation. Higher AEC was directly related with platelets count (p < 0.001), haemoglobin levels (p = 0.02), white blood cells count (p = 0.02), higher serum creatinine (p < 0.001), triglycerides (p < 0.001) and glycosylated haemoglobin (p < 0.001), while inversely with HDL cholesterol (p < 0.001). AEC was associated with multivessel disease (p = 0.03), chronic occlusions (p = 0.01), in-stent restenosis (p = 0.002), while inversely with the presence of intracoronary thrombus (p < 0.001). A significant relationship was found between AEC and the prevalence of coronary artery disease (p = 0.049), but not for the extent of more severe LM/trivessel CAD (p = 0.31). At multivariate analysis no independent role of eosinophils was found for CAD (adjusted OR [95 % CI] = 1.02 [0.91-1.15], p = 0.70), or severe CAD (adjusted OR [95 % CI] = 0.99 [0.89-1.1], p = 0.9), even when considering separately acute and elective patients. In conclusion, among patients undergoing coronary angiography, higher eosinophils levels are not independently associated with the prevalence and extent of coronary artery disease, but appear confounded by their link with major cardiovascular risk factors.
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Affiliation(s)
- Monica Verdoia
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University, C.so Mazzini, 18, 28100, Novara, Italy
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6
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Van't Hof A, Giannini F, Ten Berg J, Tolsma R, Clemmensen P, Bernstein D, Coste P, Goldstein P, Zeymer U, Hamm C, Deliargyris E, Steg PG. ST-segment resolution with bivalirudin versus heparin and routine glycoprotein IIb/IIIa inhibitors started in the ambulance in ST-segment elevation myocardial infarction patients transported for primary percutaneous coronary intervention: The EUROMAX ST-segment resolution substudy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:404-411. [PMID: 26250825 DOI: 10.1177/2048872615598633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Myocardial reperfusion after primary percutaneous coronary intervention (PCI) can be assessed by the extent of post-procedural ST-segment resolution. The European Ambulance Acute Coronary Syndrome Angiography (EUROMAX) trial compared pre-hospital bivalirudin and pre-hospital heparin or enoxaparin with or without GPIIb/IIIa inhibitors (GPIs) in primary PCI. This nested substudy was performed in centres routinely using pre-hospital GPI in order to compare the impact of randomized treatments on ST-resolution after primary PCI. METHODS Residual cumulative ST-segment deviation on the single one hour post-procedure electrocardiogram (ECG) was assessed by an independent core laboratory and was the primary endpoint. It was calculated that 762 evaluable patients were needed to show non-inferiority (85% power, alpha 2.5%) between randomized treatments. RESULTS A total of 871 participated with electrocardiographic data available in 824 patients (95%). Residual ST-segment deviation one hour after PCI was 3.8±4.9 mm versus 3.9±5.2 mm for bivalirudin and heparin+GPI, respectively ( p=0.0019 for non-inferiority). Overall, there were no differences between randomized treatments in any measures of ST-segment resolution either before or after the index procedure. CONCLUSIONS Pre-hospital treatment with bivalirudin is non-inferior to pre-hospital heparin + GPI with regard to residual ST-segment deviation or ST-segment resolution, reflecting comparable myocardial reperfusion with the two strategies.
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Affiliation(s)
| | | | | | | | | | | | - Pierre Coste
- 6 Centre Hospitalier Universitaire Bordeaux, Université de Bordeaux, France
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7
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De Luca G, Savonitto S, van’t Hof AWJ, Suryapranata H. Platelet GP IIb-IIIa Receptor Antagonists in Primary Angioplasty: Back to the Future. Drugs 2015; 75:1229-53. [DOI: 10.1007/s40265-015-0425-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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8
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Wong CK, Gao W, White HD. ST deviations and serial changes after reperfusion therapy in patients with inferior STEMIs: Relationship between inferior leads, medial chest leads and lateral leads. Int J Cardiol 2015; 184:348-349. [PMID: 25744327 DOI: 10.1016/j.ijcard.2015.02.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 02/21/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Cheuk-Kit Wong
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Wanzhen Gao
- HERO-2 trial ECG study statistician, New Zealand
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
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9
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Verdoia M, Schaffer A, Barbieri L, Suryapranata H, De Luca G. Bivalirudin as compared to unfractionated heparin in patients undergoing percutaneous coronary revascularization: A meta-analysis of 22 randomized trials. Thromb Res 2015; 135:902-15. [PMID: 25772138 DOI: 10.1016/j.thromres.2015.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/19/2015] [Accepted: 03/03/2015] [Indexed: 12/28/2022]
Abstract
UNLABELLED Bivalirudin has gained ground against unfractionated heparin (UFH) in percutaneous coronary interventions (PCI), due to a reported better safety profile. However, whether bivalirudin may provide also advantages in clinical outcome beyond the known benefits in major bleedings, is still a debated matter and was, therefore, the aim of present meta-analysis of randomized trials, evaluating efficacy and safety of bivalirudin as compared with UFH in PCI. METHODS AND STUDY OUTCOMES Literature archives (Pubmed, EMBASE, Cochrane) and main scientific sessions were scanned. Primary endpoint was overall mortality. Secondary endpoints were: 1) mortality within 30-days; 2) overall and within 30-days non fatal myocardial infarction; 3) overall and within 30-days stent thrombosis. Safety endpoints were major bleedings (per protocol definition or TIMI classification). A prespecified analysis was conducted according to clinical presentation (Elective, ACS, STEMI). RESULTS A total of 22 randomized clinical were finally included, involving 40156 patients randomized to bivalirudin (52.9%) or to UFH (47.1%). Death occurred in 1100 (2.8%) of patients, with no difference between bivalirudin and UFH (2.7% vs 2.8% OR[95%C]=0.94[0.83,-.06], p=0.32, phet=0.48). The results did not change according to clinical presentation. By meta-regression analysis, the effects on mortality were not related to patients risk profile (r=-0.38(-0.89-0.14), p=0.15) or the reduction in bleeding complications (r=-0.008(-0.86-0.85), p=0.98). A significant increase in short-term stent thrombosis was observed with bivalirudin (OR[95%CI]=1.42 [1.10-1.83], p=0.006). However, Bivalirudin significantly reduced bleedings according to both study protocol definition (OR[95%CI]=0.62[0.56-0.69],p<0.00001; phet=0.0003) or TIMI major criteria (OR[95%CI]=0.65[0.53-0.79],p<0.0001, phet=0.95). CONCLUSIONS In present meta-analysis, among patients undergoing PCI, bivalirudin, as compared with UFH, is associated with a significant reduction in major bleeding complications that, however, does not translate into mortality benefits. Furthermore, bivalirudin is associated with higher rate of 30-days stent thrombosis and recurrent MI among STEMI patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Alon Schaffer
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Lucia Barbieri
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | | | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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Verdoia M, Schaffer A, Suryapranata H, De Luca G. Effects of HDL-modifiers on cardiovascular outcomes: a meta-analysis of randomized trials. Nutr Metab Cardiovasc Dis 2015; 25:9-23. [PMID: 25439661 DOI: 10.1016/j.numecd.2014.09.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/28/2014] [Accepted: 09/15/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIM High density lipoproteins (HDL) have been addressed as a potential strategy for cardiovascular prevention, with great controversies on pharmacological approaches for HDL-elevation. Our aim was to compare HDL-rising treatment with niacin or CETP-inhibitors with optimal medical therapy in cardiovascular outcome. METHODS AND RESULTS Randomized trials were searched. Primary endpoint was cardiovascular death, secondary were: non fatal myocardial infarction; coronary revascularization; cerebrovascular accidents and safety endpoints. As many as 18 randomized trials, for a total of 69,515 patients, were included. HDL-modifiers did not reduce cardiovascular mortality (2.3%vs3.4%; OR [95%CI] = 0.96 [0.87-1.05], p = 0.37, phet = 0.58), with no benefit from niacin/CETP inhibitors according to patients' risk profile (beta [95%CI] = -0.14 [-0.29 to 0.02], p = 0.09) or the amount of HDL increase (beta [95%CI] = 0.014 [-0.008 to 0.04], p = 0.21). Niacin but not CETP-I reduced myocardial infarction and coronary revascularization, but higher rate of SAE occurred with HDL-modifiers (OR [95%CI] = 1.24 [1.18-1.31], p < 0.00001, phet = 0.02), in particular new onset of diabetes with niacin and worsening of hypertension with CETP-inhibitors. CONCLUSIONS Niacin and CETP inhibitors do not influence cardiovascular mortality. Significant benefits in MI and coronary revascularization were observed with niacin, despite the higher occurrence of diabetes.
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Affiliation(s)
- M Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - A Schaffer
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - H Suryapranata
- Department of Cardiology, UMC St Radboud, Nijmegen, The Netherlands
| | - G De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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11
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Verdoia M, Cassetti E, Schaffer A, Di Giovine G, De Luca G. Platelet glycoprotein IIIa Leu33Pro gene polymorphism and coronary artery disease: A meta-analysis of cohort studies. Platelets 2014; 26:530-5. [PMID: 25167197 DOI: 10.3109/09537104.2014.948839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Great interest has been focused in the last year on genetic predictors of cardiovascular risk. Glycoprotein IIb/IIIa (GP IIb/IIIa), fibrinogen receptor, is the final common pathway for aggregation and a key point for atherothrombosis. A single nucleotide polymorphism of IIIa subunit (Leu33Pro-PlA(1)/PlA(2) allele) has been suggested to increase aggregation and adhesion, however, contrasting reports have been reported so far on its effects on coronary artery disease (CAD). Aim of the current study was to perform a large meta-analysis including cohorts of patients undergoing coronary angiography in order to evaluate whether this polymorphism is associated with coronary artery disease. Literature archives (Pubmed, EMBASE, Cochrane) and main scientific sessions abstracts were scanned for data of consecutive cohorts of patients undergoing coronary angiography, where PlA genotype was assessed. Primary endpoint was the prevalence of CAD. Secondary endpoint was severity of CAD defined as prevalence of multivessel disease (≥2 vessels). Data from seven studies were extracted, including a final number of 6700 patients. Among them 1893 (28.3%) carried the PlA(2) polymorphism, 163 of them in homozygosis. Angiographically defined CAD was present in 3573 (74.3%) PlA(1)/PlA(1) patients and in 1430 (75.5%) PlA(2) carriers. PlA(2) polymorphism was not associated with an increased prevalence of coronary artery disease, (OR [95% CI] = 1.07 [0.95-1.21], p = 0.28, pheterogeneity = 0.39). Similar results were obtained for multivessel disease (OR [95% CI] = 1.07[0.95-1.20], p = 0.27, pheterogeneity = 0.12). Meta-regression analysis demonstrated a significant inverse relationship between the risk of CAD among the PlA(2) carriers and ageing (r = -0.044, (-0.09, -0.0008), p = 0.046). Present meta-analysis demonstrates that 33Leu → Pro substitution of GPIIIa does not influence the prevalence and extent of angiographically defined coronary artery disease in general population, although apparently playing a role among younger patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University , Novara , Italy
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12
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De Luca G, Dirksen MT, Spaulding C, Kelbæk H, Schalij M, Thuesen L, van der Hoeven B, Vink MA, Kaiser C, Musto C, Chechi T, Spaziani G, de la Llera LSD, Pasceri V, Di Lorenzo E, Violini R, Suryapranata H, Stone GW. Drug-eluting stents in patients with anterior STEMI undergoing primary angioplasty: a substudy of the DESERT cooperation. Clin Res Cardiol 2014; 103:685-99. [PMID: 24687617 DOI: 10.1007/s00392-014-0702-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 03/11/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Several concerns have emerged on the higher risk of in-stent thrombosis after drug-eluting stent (DES) implantation, especially in the setting of STEMI patients. Few data have even been reported in high-risk patients, such as those with anterior MI. Therefore this represents the aim of the current study. METHODS The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of DES for STEMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, stenting, DES, sirolimus-eluting stent (SES), Cypher, paclitaxel-eluting stent (PES), Taxus. No language restrictions were enforced. RESULTS Individual patient's data were obtained from 11 out of 13 trials, including a total of 2,782 patients with anterior MI [1,739 or 62.5% randomized to DES and 1,043 or 37.5% randomized to bare-metal stent (BMS)]. At long-term follow-up, no significant benefit was observed with DES as compared to BMS in terms of mortality [9.8 vs 10.9%, HR (95% CI) = 0.81 (0.61, 1.07), p = 0.13, p heterogeneity = 0.18], reinfarction [8.8 vs 6.4%, respectively; HR (95% CI) = 1.14 (0.80, 1.61), p = 0.47, p heterogeneity = 0.82], and stent thrombosis [5.6 vs 5%, OR (95% CI) = 0.88 (0.59, 1.30), p = 0.51, p heterogeneity = 0.65], whereas DES was associated with a significant reduction in terms of target-vessel revascularization (TVR) [13.7 vs 23.4%; OR (95% CI) = 0.56 (0.46, 0.69), p < 0.0001, p het = 0.81] that was observed at both early (within 1 year) [7 vs 14.7%, HR (95% CI) = 0.56 (0.46, 0.69), p < 0.0001, p het = 0.81] and late (>1 year) follow-up [7.2 vs 9%, HR (95% CI) = 0.67 (0.47, 0.96), p = 0.03, p het = 0.96]. CONCLUSIONS This study showed that among patients with anterior STEMI undergoing primary angioplasty, SES and PES, as compared to BMS, are associated with a significant reduction in TVR at long-term follow-up. No concerns were found with the use of first-generation DES in terms of mortality.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University, C.so Mazzini, 18, 24100, Novara, Italy,
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13
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Steg PG, van ‘t Hof A, Clemmensen P, Lapostolle F, Dudek D, Hamon M, Cavallini C, Gordini G, Huber K, Coste P, Thicoipe M, Nibbe L, Steinmetz J, Ten Berg J, Eggink GJ, Zeymer U, Campo dell' Orto M, Kanic V, Deliargyris EN, Day J, Schuette D, Hamm CW, Goldstein P. Design and methods of European Ambulance Acute Coronary Syndrome Angiography Trial (EUROMAX): an international randomized open-label ambulance trial of bivalirudin versus standard-of-care anticoagulation in patients with acute ST-segment-elevation myocardial infarction transferred for primary percutaneous coronary intervention. Am Heart J 2013; 166:960-967.e6. [PMID: 24268209 DOI: 10.1016/j.ahj.2013.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI) triaged to primary percutaneous coronary intervention (PCI), anticoagulation often is initiated in the ambulance during transfer to a PCI site. In this prehospital setting, bivalirudin has not been compared with standard-of-care anticoagulation. In addition, it has not been tested in conjunction with the newer P2Y12 inhibitors prasugrel or ticagrelor. DESIGN EUROMAX is a randomized, international, prospective, open-label ambulance trial comparing bivalirudin with standard-of-care anticoagulation with or without glycoprotein IIb/IIIa inhibitors in 2200 patients with STEMI and intended for primary percutaneous coronary intervention (PCI), presenting either via ambulance or to centers where PCI is not performed. Patients will receive either bivalirudin given as a 0.75 mg/kg bolus followed immediately by a 1.75-mg/kg per hour infusion for ≥30 minutes prior to primary PCI and continued for ≥4 hours after the end of the procedure at the reduced dose of 0.25 mg/kg per hour, or heparins at guideline-recommended doses, with or without routine or bailout glycoprotein IIb/IIIa inhibitor treatment according to local practice. The primary end point is the composite incidence of death or non-coronary-artery-bypass-graft related protocol major bleeding at 30 days by intention to treat. CONCLUSION The EUROMAX trial will test whether bivalirudin started in the ambulance and continued for 4 hours after primary PCI improves clinical outcomes compared with guideline-recommended standard-of-care heparin-based regimens, and will also provide information on the combination of bivalirudin with prasugrel or ticagrelor.
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14
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Verdoia M, Secco GG, Barbieri L, Cassetti E, Schaffer A, Sinigaglia F, Marino P, Suryapranata H, De Luca G. Platelet HPA-1 a/HPA-1 b polymorphism and the risk of periprocedural myocardial infarction in patients undergoing elective PCI. Platelets 2013; 25:367-72. [PMID: 24283589 DOI: 10.3109/09537104.2013.821602] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Periprocedural myocardial infarction (PMI) represents a relatively common complication of percutaneous coronary intervention (PCI) and large interests have been focused on platelets in order to prevent such a complication. The single nucleotide polymorphism Leu33Pro of platelet glycoprotein IIIa has been related to an increased platelet reactivity, a lower response to antiplatelet agents and higher risk of stent restenosis. Therefore, aim of our study was to evaluate the impact of this polymorphism on PMI in elective patients undergoing PCI. Our population is represented by 422 consecutive patients with cardiac biomarkers within normality undergoing elective PCI. We measured cardiac biomarkers (CK-MB and Troponin I) at baseline, and 8, 24 and 48 hours after the procedure. For all subjects, we performed genetic analysis to assess the presence of Leu33Pro polymorphism. A total of 136 patients (32.2%) were polymorphic. Those patients were younger (p = 0.03) and more often dislypidemic (p = 0.01). Angiographic features did not differ according to genetic status. Pharmacological treatment pre and during angioplasty was similar. PCI-related complications did not differ according to genotype, with the only exception of higher rate of distal embolization in polymorphic patients. However, Leu33Pro polymorphism was not associated with increased risk of periprocedural myonecrosis and PMI even after correction for baseline differences, (respectively OR = 1.22 [0.81-1.84], p = 0.34 for myonecrosis and OR = 1.66 [0.85-3.23]; p = 0.14 for PMI). At subgroup analysis, the Leu33Pro substitution was associated with higher risk of PMI only among diabetics (adjusted OR = 4.46 [1.12-17.76], p = 0.03). Among patients undergoing elective PCI, the polymorphism Leu33Pro of platelet glycoprotein IIIa is associated with increased risk of PMI only in diabetic patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University , Novara , Italy
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Hahn JY, Song YB, Kim EK, Yu CW, Bae JW, Chung WY, Choi SH, Choi JH, Bae JH, An KJ, Park JS, Oh JH, Kim SW, Hwang JY, Ryu JK, Park HS, Lim DS, Gwon HC. Ischemic postconditioning during primary percutaneous coronary intervention: the effects of postconditioning on myocardial reperfusion in patients with ST-segment elevation myocardial infarction (POST) randomized trial. Circulation 2013; 128:1889-96. [PMID: 24068776 DOI: 10.1161/circulationaha.113.001690] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ischemic postconditioning has been reported to reduce infarct size in patients with ST-segment-elevation myocardial infarction. However, cardioprotective effects of postconditioning have not been demonstrated in a large-scale trial. METHODS AND RESULTS We performed a multicenter, prospective, randomized, open-label, blinded end-point trial. A total of 700 patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction within 12 hours after symptom onset were randomly assigned to the postconditioning group or to the conventional primary PCI group in a 1:1 ratio. Postconditioning was performed immediately after restoration of coronary flow as follows: The angioplasty balloon was positioned at the culprit lesion and inflated 4 times for 1 minute with low-pressure (<6 atm) inflations, each separated by 1 minute of deflation. The primary end point was complete ST-segment resolution (percentage resolution of ST-segment elevation >70%) measured at 30 minutes after PCI. Complete ST-segment resolution occurred in 40.5% of patients in the postconditioning group and 41.5% of patients in the conventional PCI group (absolute difference, -1.0%; 95% confidence interval, -8.4 to 6.4; P=0.79). The rate of myocardial blush grade of 0 or 1 and the rate of major adverse cardiac events (a composite of death, myocardial infarction, severe heart failure, or stent thrombosis) at 30 days did not differ significantly between the postconditioning group and the conventional PCI group (17.2% versus 22.4% [P=0.20] and 4.3% versus 3.7% [P=0.70], respectively). CONCLUSION Ischemic postconditioning did not improve myocardial reperfusion in patients with ST-segment-elevation myocardial infarction undergoing primary PCI with current standard practice.
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Affiliation(s)
- Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-Y. Hahn; Y.B.S., E.K.K., S.-H.C., J.-H.C., H.-C.G.); Sejong General Hospital, Bucheon, Korea (C.W.Y.); Chungbuk National University Hospital, Cheongju, Korea (J.-W.B.); Seoul National University, Boramae Medical Center, Seoul, Korea (W.-Y.C.); Konyang University Hospital, Daejon, Korea (J.-H.B.); KEPCO Medical Center, Seoul, Korea (K.J.A.); Yeungnam University Hospital, Daegu, Korea (J.-S.P.); Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea (J.H.O.); Chung-Ang University Hospital, Seoul, Korea (S.-W.K.); Gyeongsang National University Hospital, Jinju, Korea (J.-Y. Hwang); Daegu Catholic University Medical Center, Daegu, Korea (J.K.R.); Kyungpook National University Hospital, Daegu, Korea (H.S.P.); and Korea University Anam Hospital, Seoul, Korea (D.-S.L.)
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16
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De Luca G, Parodi G, Sciagrà R, Venditti F, Bellandi B, Vergara R, Migliorini A, Valenti R, Antoniucci D. Time-to-treatment and infarct size in STEMI patients undergoing primary angioplasty. Int J Cardiol 2013; 167:1508-13. [DOI: 10.1016/j.ijcard.2012.04.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 03/05/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
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17
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Verdoia M, Camaro C, Barbieri L, Schaffer A, Marino P, Bellomo G, Suryapranata H, De Luca G. Mean platelet volume and the risk of periprocedural myocardial infarction in patients undergoing coronary angioplasty. Atherosclerosis 2013; 228:136-41. [PMID: 23518179 DOI: 10.1016/j.atherosclerosis.2013.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 01/04/2013] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Periprocedural myocardial infarction (PMI) represents a relatively common complication of percutaneous coronary intervention (PCI). Mean platelet volume (MPV) has been proposed as a marker for platelet activation, as larger sized platelets have been associated with higher pro-thrombotic risk. Therefore, aim of the current study was to evaluate whether MPV is associated with increased risk of PMI after PCI. METHODS We included 1056 consecutive patients undergoing PCI. We measured myonecrosis biomarkers at intervals from 6 to 48 h after PCI. Periprocedural myonecrosis was defined for troponin I increase by 3 times the ULN or by 50% if elevated at the time of the procedure. PMI was defined as CK-MB increase by 3 times the ULN or 50% if elevated at the time of the procedure. RESULTS We grouped patients according to tertiles values of MPV (<10.4 fl; 10.5-11.3 fl; >11.4 fl). High MPV was associated with diabetes (p = 0.025) and higher prevalence of cerebrovascular events (p = 0.005). MPV significantly related with haemoglobin levels (p < 0.001), but inversely to platelet count (p < 0.001) and higher presence of thrombus (p = 0.03). Larger sized platelets did not increase risk of periprocedural myonecrosis (p = 0.91; OR[95% CI] = 1.04[0.90-1.2], p = 0.64) or PMI (p = 0.09; OR[95%IC] = 1.13[0.93-1.37]; p = 0.20). Subgroup analysis confirmed no impact of MPV on periprocedural MI also in high-risk subsets of patients, such as those with ACS at presentation (OR[95%CI] = 1.09 [0.87-1.38]; p = 0.44), diabetes (OR[95% CI] = 1.02[0.71-1.47], p = 0.91), female gender (OR [95% CI] = 1.15 [0.78-1.71], p = 0.48), elderly patients (age ≥ 75 years) (OR[95%CI] = 1.21[0.87-1.69], p = 0.25) or with renal failure (OR[95%CI] = 1.55[0.91-2.61], p = 0.1). CONCLUSIONS This study demonstrates that MPV does not predict the risk of PMI in patients undergoing PCI.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria Maggiore della Carità, Cso Mazzini 18, Eastern Piedmont University, Novara 28100, Italy
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Balghith MA. High Bolus Tirofiban vs Abciximab in Acute STEMI Patients Undergoing Primary PCI - The Tamip Study. Heart Views 2012; 13:85-90. [PMID: 23181175 PMCID: PMC3503360 DOI: 10.4103/1995-705x.102145] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Primary percutaneous coronary intervention (PCI) has been shown to be an effective therapy for patients with acute myocardial infarction (MI). Glycoprotein (GP) IIb/IIIa receptor blockers reduce thrombotic complications in patients undergoing PCI. Most available data relate to Reopro, which has been registered for this indication. GP IIb/IIIa reduce unfavorable outcome in U/A and non ST-elevation myocardial infarction (STEMI) patients. Only few studies focused on high dose Aggrastat for STEMI patients in the emergency department (ED) before PCI. The aim is to increase the patency during the time awaiting coronary angioplasty in patients with acute MI. OBJECTIVES To study the effect of upfront high bolus dose (HDR) of tirofiban on the extent of residual ST segment deviation 1 hour after primary PCI and the incidence of TIMI 3 flow of the infarct-related artery (IRA). MATERIALS AND METHODS A randomized, open label, single center study in the ED. A total of 90 patients with acute ST-elevation MI, diagnosed clinically by ECG criteria (ST segment elevation of >2 mm in two adjacent ECG leads), and with an expectation that a patient will undergo primary PCI. Patients were aged 21-85 years and all received heparin 5000 u, aspirin 160 mg, and Plavix 600 mg. Patients were divided in two groups (group I: triofiban high bolus vs group II: Reopro) with 45 patients in each group. In group I, high bolus triofiban 25 mcg/kg over 3 min was started in the ED with maintenance infusion of 0.15 mcg/ kg/min continued for 12 hours and transferred to cath lab for PCI. Patients in group II were transferred to cath lab, where a standard dose of Reopro was given with a bolus of 0.25 mcg/kg and maintenance infusion of 0.125 mcg/kg/min over 12 hours. RESULTS ST segment resolution and TIMI flow were evaluated in both groups before and after PCI. Thirty-five patients (78%) enrolled in group I and 29 patients (64%) in group II had resolution of ST segment (P-value 0.24). Twenty-one patients (47% group I) vs 23 patients (51% group II) with P-value 0.83 achieved TIMI 0 flow. Twenty-four patients (53% group I) compared with 22 patients (49% group II) with P-value 0.83 had TIMI 1 to 3 flow before PCI. TIMI 3 flow was achieved in 40 patients (89% group I) compared with 38 patients (84% group II) with P-value 0.76. CONCLUSION In this study there was a trend toward better ST segment resolution and patency of IRA (i.e., improved TIMI flow) in patients given high bolus dose Aggrastat in the ED. Larger studies are needed to confirm this finding.
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Affiliation(s)
- Mohammed A. Balghith
- King Abdulaziz Cardiac Center, King Saud Bin Abdulaziz University for Health Science, National Guard, Riyadh, Saudi Arabia
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Usefulness of SUM of ST-segment elevation on electrocardiograms (limb leads) for predicting in-hospital complications in patients with stress (takotsubo) cardiomyopathy. Am J Cardiol 2012; 109:1651-6. [PMID: 22440122 DOI: 10.1016/j.amjcard.2012.01.393] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 01/26/2012] [Accepted: 01/26/2012] [Indexed: 11/21/2022]
Abstract
Although the prognosis of patients with stress (takotsubo) cardiomyopathy is relatively favorable, serious complications occur in some patients. It is generally accepted that electrocardiography is an essential tool for the diagnosis of stress cardiomyopathy, with findings highly suggestive of the characteristics of myocardial damage. We tested the hypothesis that the quantitative analysis of electrocardiograhic changes can predict complications in stress cardiomyopathy. The study subjects were 85 patients with stress cardiomyopathy. A total of 34 patients developed ≥1 in-hospital complications (heart failure, intraventricular pressure gradient [>30 mm Hg], cardiogenic shock, ventricular tachycardia/fibrillation, and embolism). Patients with complications were likely to have a higher heart rate (96 ± 25 vs 76 ± 17 beats/min, p <0.001), larger sum of ST-segment elevation in 12 leads (median 10.5 mm; interquartile range 5.0 to 17.5 vs 3.0 mm, interquartile range 0 to 7.0; p <0.001) and extension of ST-segment elevation to limb leads (50% vs 12%, p <0.001) than those without complications. Multivariate logistic regression analysis identified heart rate (odds ratio 1.05, 95% confidence interval 1.02 to 1.07, p = 0.001) and sum of ST-segment elevation in 12 leads (odds ratio 1.24, 95% confidence interval 1.11 to 1.39, p <0.001) as significant and independent predictors of complications. Receiver operating characteristic analysis selected 5.5 mm as the best cutoff value of sum of ST-segment elevation in 12 leads for the prediction of complications, with a sensitivity and specificity of 74% and 73%, respectively, and area under the curve of 0.81 (95% confidence interval 0.72 to 0.90, p <0.001). The results suggest that the extent and magnitude of ST-segment elevation on the electrocardiogram are potentially useful predictors of in-hospital complications in patients with stress cardiomyopathy.
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Heestermans T, de Boer MJ, van Werkum JW, Mosterd A, Gosselink ATM, Dambrink JHE, van Houwelingen G, Koopmans P, Hamm C, Zijlstra F, ten Berg JM, van 't Hof AWJ. Higher efficacy of pre-hospital tirofiban with longer pre-treatment time to primary PCI: protection for the negative impact of time delay. EUROINTERVENTION 2011; 7:442-8. [PMID: 21764662 DOI: 10.4244/eijv7i4a73] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To evaluate the impact of longer duration of pre-hospital initiated antiplatelet and antithrombotic therapy on outcome in patients with ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS In this sub-analysis of the Ongoing Tirofiban in Myocardial Evaluation (On-TIME) 2 trial, we studied, in 1,370 patients, the effect of pre-treatment time (time from administering study medication to time of angiography) on complete ST-segment resolution (STR), initial patency and 30-day mortality. Study medication consisted of high dose tirofiban (HDT) or control (placebo or no HDT) on top of high dose clopidogrel, aspirin and unfractionated heparin. Median pre-treatment time was 55 min (44-70). Longer pre-treatment was associated with longer transportation times, longer in-hospital delay, longer total ischaemic time (all p<0.001) and higher 30-day mortality (3.6% vs. 1.8%, p=0.046). Longer HDT pre-treatment time was independently associated with increased complete STR both before (odds ratio [OR] 1.51, 95%; confidence interval [CI] 0.98-2.32; p=0.06) and after PCI (OR 1.43, 95%; CI 1.02-2.02; p=0.039) and with a significantly improved initial TIMI 2 or 3 flow (51.4% vs. 43.4%, p=0.042) and reduced 30-day mortality (2.1% vs. 5.0%, p=0.047) as compared to longer control pre-treatment. CONCLUSIONS Longer time delay before primary PCI is associated with increased mortality. Pre-treatment with high dose tirofiban, however, may compensate for this negative effect by improving ST-segment resolution and initial patency and by reducing mortality. Further studies should be performed to confirm that this is an attractive therapy for patients with longer delays to reperfusion.
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Affiliation(s)
- Ton Heestermans
- Department of Cardiology, Medisch Centrum Alkmaar, Alkmaar, The Netherlands
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Woo JS, Cho JM, Kim SJ, Kim MK, Kim CJ. Combined Assessments of Biochemical Markers and ST-Segment Resolution Provide Additional Prognostic Information for Patients With ST-Segment Elevation Myocardial Infarction. Korean Circ J 2011; 41:372-8. [PMID: 21860638 PMCID: PMC3152731 DOI: 10.4070/kcj.2011.41.7.372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 10/26/2010] [Indexed: 11/11/2022] Open
Abstract
Background and Objectives The prognostic value of biochemical markers and the resolution of ST-segment elevation on electrocardiogram are well established. However, how a combination of these two tools affects the evaluation of risk stratification has not yet been evaluated. Subjects and Methods Between January 2006 and June 2008, 178 consecutive patients treated with primary percutaneous coronary interventions after ST-segment elevation myocardial infarctions (STEMI) were analyzed at two coronary care units. Patients were divided into the following three groups according to ST-segment resolution: complete (≥70% depression of the elevated ST-segment, n=63), partial (30% to 70%, n=90), and incomplete (<30%, n=25). Demographic data, including history, electrocardiography, biochemical markers, initial ejection fraction, and angiographic findings were also evaluated. Results There were 7 deaths, 3 repeated myocardial infarctions, and 17 readmissions for worsening heart failure during six months of follow-up. In a multivariate analysis to predict clinical outcomes, ejection fraction {hazard ratio (HR): 0.83 (0.76-0.91), p<0.01}, high-sensitivity C-reactive protein {HR: 1.15 (1.05-1.26), p<0.05}, and the degree of ST-segment resolution {HR: 0.96 (0.93-0.09), p<0.05} were independently associated with clinical outcomes. According to the Cox-proportional hazards model, the addition of ST-segment resolution markedly improved the prognostic utility of the model containing biochemical markers and ejection fraction. Conclusion Assessment of biomarkers upon admission and ST-segment resolution are strong predictors of clinical outcomes. The combination of these data provides additive information about prognosis at an early point in the disease progression and further improves risk stratification for STEMI.
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Affiliation(s)
- Jong Shin Woo
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Kyung Hee University, Seoul, Korea
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The impact of age on effects of pre-hospital initiation of high bolus dose of tirofiban before primary angioplasty for ST-elevation myocardial infarction. Cardiovasc Drugs Ther 2011; 25:323-30. [PMID: 21744314 DOI: 10.1007/s10557-011-6314-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Glycoprotein IIb/IIIa inhibitors are favourable in ST-elevation myocardial infarction (STEMI) patients, and the additional value of early pre-hospital high bolus dose tirofiban has recently been established. The aim of this study was to determine the impact of age on myocardial reperfusion and clinical outcomes of pre-hospital administration of high bolus dose tirofiban. METHODS This is a pre-specified sub-analysis of the multicentre, double-blind, placebo-controlled, randomised On-TIME 2 trial and it's open label phase. The primary endpoint was mean residual ST segment deviation 1 h after primary PCI and was evaluated in three age groups. RESULTS Of the 466 patients in the highest tertile (≥68 years), median age was 74.4 years (IQR 71.3-78.6 years) and 231 (50%) were randomised to tirofiban. Mean residual ST segment deviation 1 h after PCI was significantly lower in elderly patients pre-treated with tirofiban compared to elderly patients without tirofiban pre-treatment (4.2 ± 5.2 mm vs 6.4 ± 7.5 mm, p = 0.001). Furthermore, elderly patients pre-treated with tirofiban had a non-significantly higher rate of 30-day major or minor bleeding compared to elderly patients without tirofiban pre-treatment (14.2% vs 9.0%, p = 0.088). 30-day net adverse clinical events in elderly patients with- or without tirofiban was not significantly different (11.9% vs 15.2%, p = 0.300). CONCLUSION The effect of pre-hospital initiation of high bolus dose tirofiban on myocardial reperfusion, as determined by ST-segment resolution is highest in the elderly patients. However, this was associated with a trend towards more bleeding complications, resulting in a balanced clinical effect after 30-day follow-up. Future studies should evaluate whether the elderly STEMI patient may benefit from highly effective and safer antiplatelet therapy.
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Facilitated reperfusion with prehospital glycoprotein IIb/IIIa inhibition: predictors of complete ST-segment resolution before primary percutaneous coronary intervention in the On-TIME 2 trial. J Electrocardiol 2011; 44:42-8. [DOI: 10.1016/j.jelectrocard.2010.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Indexed: 11/24/2022]
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Verouden NJ, Haeck JD, Kuijt WJ, van Geloven N, Koch KT, Henriques JP, Baan J, Vis MM, Piek JJ, Tijssen JG, de Winter RJ. Prediction of 1-Year Mortality With Different Measures of ST-Segment Recovery in All-Comers After Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2010; 3:522-9. [DOI: 10.1161/circoutcomes.109.923797] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Post hoc analyses from several randomized, controlled trials have established the prognostic importance of different measures of ST-segment recovery in highly selected patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment–elevation myocardial infarction (STEMI). In this single-center registry, we investigated whether various measures of ST-segment recovery can be applied to unselected STEMI patients undergoing primary PCI.
Methods and Results—
We analyzed 12-lead ECGs from 2124 consecutive STEMI patients who underwent primary PCI at our institution between November 1, 2000, and January 1, 2007. ECGs were recorded at the catheterization laboratory immediately before arterial puncture and at the end of PCI. We examined measures assessing ST-segment recovery on the postprocedural ECG and measures comparing both ECGs and related these to 1-year, all-cause mortality. Cumulative ST-segment recovery (∑ST-D resolution) at a 50% cutoff had the highest unadjusted accuracy (C statistic, 0.646; 95% confidence interval, 0.602 to 0.689;
P
<0.001) as compared with the other 8 measures evaluated. Furthermore, ∑ST-D resolution was the strongest contributor to both the net reclassification and integrated discrimination improvement.
Conclusions—
Although each measure of ST-segment recovery provided univariable prognostic information, the ∑ST-D resolution measure comparing summed ST-segment deviations on the preprocedural and postprocedural ECG was the best independent predictor of 1-year mortality in all-comer STEMI patients after primary PCI.
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Affiliation(s)
- Niels J.W. Verouden
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Joost D.E. Haeck
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Wichert J. Kuijt
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Nan van Geloven
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Karel T. Koch
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - José P.S. Henriques
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Baan
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Marije M. Vis
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J. Piek
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Jan G.P. Tijssen
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J. de Winter
- From the Department of Cardiology of the Academic Medical Center–University of Amsterdam, Amsterdam, The Netherlands
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Timmer J, ten Berg J, Heestermans A, Dill T, van Werkum J, Dambrink J, Suryapranata H, Ottervanger J, Hamm C, van ‘t Hof A. Pre-hospital administration of tirofiban in diabetic patients with ST-elevation myocardial infarction undergoing primary angioplasty: a sub-analysis of the On-Time 2 trial. EUROINTERVENTION 2010; 6:336-42. [DOI: 10.4244/eijv6i3a56] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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26
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Early dynamic risk stratification with baseline troponin levels and 90-minute ST-segment resolution to predict 30-day cardiovascular mortality in ST-segment elevation myocardial infarction: analysis from CLopidogrel as Adjunctive ReperfusIon TherapY (CLARITY)-Thrombolysis in Myocardial Infarction (TIMI) 28. Am Heart J 2010; 159:964-971.e1. [PMID: 20569707 DOI: 10.1016/j.ahj.2010.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 03/06/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Troponin is the preferred biomarker for risk stratification in non-ST elevation ACS. The incremental prognostic use of the initial magnitude of troponin elevation and its value in conjunction with ST-segment resolution (STRes) in ST elevation myocardial infarction (STEMI) is less well defined. METHODS Troponin T (TnT) was measured in 1,250 patients at presentation undergoing fibrinolysis for STEMI in CLARITY-TIMI 28. ST-segment resolution was measured at 90 minutes. Multivariable logistic regression was used to examine the independent association between TnT levels, STRes, and 30-day cardiovascular (CV) mortality. RESULTS Patients were classified into undetectable TnT at baseline (n = 594), detectable but below the median of 0.12 ng/mL (n = 330), and above the median (n = 326). Rates of 30-day CV death were 1.5%, 4.5%, and 9.5%, respectively (P < .0001). Compared with those with undetectable levels and adjusting for baseline factors, the odds ratios for 30-day CV death were 4.56 (1.72-12.08, P = .002) and 5.81 (2.29-14.73, P = .0002) for those below and above the median, respectively. When combined with STRes, there was a significant gradient of risk, and in a multivariable model both baseline TnT (P = .004) and STRes (P = .003) were significant predictors of 30-day CV death. The addition of TnT and STRes to clinical risk factors significantly improved the C-statistic (from 0.86 to 0.90, P = .02) and the integrated discriminative improvement (7.1% increase) (P = .0009). CONCLUSIONS Baseline TnT and 90-minute STRes are independent predictors of 30-day CV death in patients with STEMI. Use of these 2 simple, readily available tools can aid clinicians in early risk stratification.
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Nijveldt R, van der Vleuten PA, Hirsch A, Beek AM, Tio RA, Tijssen JGP, Piek JJ, van Rossum AC, Zijlstra F. Early electrocardiographic findings and MR imaging-verified microvascular injury and myocardial infarct size. JACC Cardiovasc Imaging 2010; 2:1187-94. [PMID: 19833308 DOI: 10.1016/j.jcmg.2009.06.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Revised: 06/16/2009] [Accepted: 06/25/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study investigated early electrocardiographic findings in relation to left ventricular (LV) function, extent and size of infarction, and microvascular injury in patients with acute myocardial infarction (MI) treated with percutaneous coronary intervention (PCI). BACKGROUND The electrocardiogram (ECG) is the most used and simplest clinical method to evaluate the risk for patients immediately after reperfusion therapy for acute MI. ST-segment resolution and residual ST-segment elevation have been used for prognosis in acute MI, whereas Q waves are related to outcome in chronic MI. We hypothesized that the combination of these electrocardiographic measures early after primary PCI would enhance risk stratification. METHODS We prospectively included 180 patients with a first acute ST-segment elevation MI to assess ST-segment resolution, residual ST-segment elevation, and number of Q waves using the 12-lead ECG acquired on admission and 1 h after successful PCI. The ECG findings were related to LV function, infarction size and transmurality, and microvascular injury as assessed with cine and gadolinium-enhanced cardiac magnetic resonance 4 +/- 2 days after reperfusion therapy. RESULTS Residual ST-segment elevation (beta = -2.00, p = 0.004) and the number of Q waves (beta = -1.66, p = 0.005) were independent ECG predictors of LV ejection fraction. Although the number of Q waves was the only independent predictor of infarct size (beta = 2.01, p < 0.001) and transmural extent of infarction (beta = 0.60, p < 0.001), residual ST-segment elevation was the only independent predictor of microvascular injury (odds ratio: 19.1, 95% confidence interval: 2.4 to 154, p = 0.005) in multivariable analyses. The ST-segment resolution was neither associated with LV function, infarct size, or transmurality indexes, nor with microvascular injury in multivariable analysis. CONCLUSIONS In patients after successful coronary intervention for acute MI, residual ST-segment elevation and the number of Q waves on the post-procedural ECG offer valuable complementary information on prediction of myocardial function and necrosis and its microvascular status.
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Affiliation(s)
- Robin Nijveldt
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands.
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Tjandrawidjaja MC, Fu Y, Westerhout CM, White HD, Todaro TG, Van de Werf F, Mahaffey KW, Wagner GS, Granger CB, Armstrong PW. Resolution of ST-segment depression: a new prognostic marker in ST-segment elevation myocardial infarction. Eur Heart J 2009; 31:573-81. [DOI: 10.1093/eurheartj/ehp494] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Gu YL, Fokkema ML, Kampinga MA, de Smet BJGL, Tan ES, van den Heuvel AFM, Zijlstra F. Intracoronary versus intravenous abciximab in ST-segment elevation myocardial infarction: rationale and design of the CICERO trial in patients undergoing primary percutaneous coronary intervention with thrombus aspiration. Trials 2009; 10:90. [PMID: 19785725 PMCID: PMC2765937 DOI: 10.1186/1745-6215-10-90] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Accepted: 09/28/2009] [Indexed: 01/09/2023] Open
Abstract
Background Administration of abciximab during primary percutaneous coronary intervention is an effective adjunctive therapy in the treatment of patients with ST-segment elevation myocardial infarction. Recent small-scaled studies have suggested that intracoronary administration of abciximab during primary percutaneous coronary intervention is superior to conventional intravenous administration. This study has been designed to investigate whether intracoronary bolus administration of abciximab is more effective than intravenous bolus administration in improving myocardial perfusion in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration. Methods/Design The Comparison of IntraCoronary versus intravenous abciximab administration during Emergency Reperfusion Of ST-segment elevation myocardial infarction (CICERO) trial is a single-center, prospective, randomized open-label trial with blinded evaluation of endpoints. A total of 530 patients with STEMI undergoing primary percutaneous coronary intervention are randomly assigned to either an intracoronary or intravenous bolus of weight-adjusted abciximab. The primary end point is the incidence of >70% ST-segment elevation resolution. Secondary end points consist of post-procedural residual ST-segment deviation, myocardial blush grade, distal embolization, enzymatic infarct size, in-hospital bleeding, and clinical outcome at 30 days and 1 year. Discussion The CICERO trial is the first clinical trial to date to verify the effect of intracoronary versus intravenous administration of abciximab on myocardial perfusion in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration. Trial registration ClinicalTrials.gov NCT00927615
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Affiliation(s)
- Youlan L Gu
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1 PO Box 30001, 9700 RB Groningen, the Netherlands.
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Park SR, Kang YR, Seo MK, Kang MK, Cho JH, An YJ, Kwak CH, Hwang SJ, Jung YH, Hwang JY. Clinical Predictors of Incomplete ST-Segment Resolution in the Patients With Acute ST Segment Elevation Myocardial Infarction. Korean Circ J 2009; 39:310-6. [PMID: 19949636 PMCID: PMC2771846 DOI: 10.4070/kcj.2009.39.8.310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 01/20/2009] [Indexed: 11/26/2022] Open
Abstract
Background and Objectives The failure of ST-segment resolution (STR) after primary percutaneous coronary intervention (pPCI) is associated with adverse clinical outcomes. However, the clinical predictors on admission for incomplete STR are poorly known. Subjects and Methods Patients undergoing pPCI (n=101, 79 males and 22 females, mean age 60.0 years) were divided into complete STR group (≥70%, n=58) and incomplete STR group (<70%, n=43). The groups were compared according to clinical factors including history, electrocardiographic (ECG) patterns, angiographic features and laboratory data. Results The incomplete STR group contained more frequent hypertensive patients (p=0.04) and patients displaying longer tendency in total chest pain duration (p=0.08). This group was associated with worse clinical factors such as low ejection fraction (p=0.06), higher Killip class (p=0.08) and more death (p=0.042). Grade 3 ischemia pattern of ECG and precordial ST elevation (i,e anterior myocardial infarction) at admission were more frequent in the incomplete STR group (p=0.001 and 0.002, respectively). Initial troponin I, creatinin kinase -MB and brain natriuretic peptide levels were higher in the incomplete STR group (p=0.001, 0.002, and 0.043, respectively). Coronary angiography showed that culprit lesions were more frequent in left anterior descending artery than other arteries in the incomplete STR group of patients (p=0.002). Thrombolysis In Myocardial Infarction (TIMI) flow grades 2 or less before PCI was more frequent in the incomplete STR group (p=0.029). However, TIMI flow grade after PCI was not appreciably different between the two groups. Logistic regression analysis demonstrated that TIMI flow grade 2 or less was most powerful predictor for incomplete STR {odds ratio (OR)=12.12, 95% confidence interval (CI) 1.23-119.35, p=0.032}. Other independent predictors were anterior infarction (OR=3.39, CI 1.46-10.57, p=0.007), ischemia grade 3 ECG at admission (OR=3.87, CI 1.31-11.41, p=0.014), and hypertensive patients (OR=3.03, CI 1.13-8.15, p=0.027). Conclusion Incomplete STR after pPCI is associated with poor prognostic clinical factors. TIMI flow grade 2 or less before pPCI, ST elevation on precordial leads, ischemia grade 3 pattern of initial ECG, and hypertensive patients are independent predictors for incomplete STR in the early stage.
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Affiliation(s)
- So Ra Park
- Department of Internal Medicine, Gyeongsang Institute of Health, School of Medicine, Gyeongsang National University, Jinju, Korea
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Salido L, Mestre JL, Pey J, Barcia F, Asín E. [Analysis of mortality in myocardial infarction patients treated with primary angioplasty]. Med Clin (Barc) 2008; 131:481-6. [PMID: 19007575 DOI: 10.1157/13127275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Primary angioplasty is an effective method to achieve myocardial reperfusion in ST-elevated myocardial infarction (MI). The objective of this study was to determine the independent factors that could predict mortality in MI patients treated with primary angioplasty and to analyze the prognostic value of tissue reperfusion parameters in those patients. PATIENTS AND METHOD A prospective observational study was performed in 380 consecutive patients with ST-elevated MI treated with primary angioplasty at a single hospital. RESULTS Early mortality was 8.9%. Upon univariate analysis, the following variables were associated with significantly higher mortality: age, ejection fraction (EF), multivascular disease, anterior location of MI, lack of resolution of ST segment, flow 0-1 of TIMI, grade 0-1 of blush index and delay time above 4 hours. Multivariate analysis yielded the following independent variables as predictors of mortality: age, degree of heart failure (Killip index) and degree of myocardial perfusion (blush index). CONCLUSIONS The independent predictive factors of mortality in patients with ST-elevated MI and treated with primary angioplasty are: age, degree of heart failure (Killip index) and degree of myocardial reperfusion (blush index). The resolution of ST segment and blush index represent additional prognostic variables in patients with good epicardial reperfusion.
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Affiliation(s)
- Luisa Salido
- Laboratorio de Hemodinamia, Servicio de Cardiología, Hospital Ramón y Cajal, Madrid, Spain.
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Van't Hof AWJ, Ten Berg J, Heestermans T, Dill T, Funck RC, van Werkum W, Dambrink JHE, Suryapranata H, van Houwelingen G, Ottervanger JP, Stella P, Giannitsis E, Hamm C. Prehospital initiation of tirofiban in patients with ST-elevation myocardial infarction undergoing primary angioplasty (On-TIME 2): a multicentre, double-blind, randomised controlled trial. Lancet 2008; 372:537-46. [PMID: 18707985 DOI: 10.1016/s0140-6736(08)61235-0] [Citation(s) in RCA: 324] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The most effective magnitude and timing of antiplatelet therapy is important in patients with acute ST-elevation myocardial infarction (STEMI). We investigated whether the results of primary coronary angioplasty (PCI) can be improved by the early administration of the glycoprotein IIb/IIIa blocker tirofiban at first medical contact in the ambulance or referral centre. METHODS We undertook a double-blind, randomised, placebo-controlled trial in 24 centres in the Netherlands, Germany, and Belgium. Between June 29, 2006, and Nov 13, 2007, 984 patients with STEMI who were candidates to undergo PCI were randomly assigned to either high-bolus dose tirofiban (n=491) or placebo (N=493) in addition to aspirin (500 mg), heparin (5000 IU), and clopidogrel (600 mg). Randomisation was by blinded sealed kits with study drug, in blocks of four. The primary endpoint was the extent of residual ST-segment deviation 1 h after PCI. Analysis was by intention to treat. The trial is registered, number ISRCTN06195297. FINDINGS 936 (95%) patients were randomly assigned to treatment after a prehospital diagnosis of myocardial infarction in the ambulance. Median time from onset of symptoms to diagnosis was 76 min (IQR 35-150). Mean residual ST deviation before PCI (10.9 mm [SD 9.2] vs 12.1 mm [9.4], p=0.028) and 1 h after PCI (3.6 mm [4.6] vs 4.8 mm [6.3], p=0.003) was significantly lower in patients pretreated with high-bolus dose tirofiban than in those assigned to placebo. The rate of major bleeding did not differ significantly between the two groups (19 [4%] vs 14 [3%]; p=0.36). INTERPRETATION Our finding that routine prehospital initiation of high-bolus dose tirofiban improved ST-segment resolution and clinical outcome after PCI, emphasises that further platelet aggregation inhibition besides high-dose clopidogrel is mandated in patients with STEMI undergoing PCI.
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van ‘t Hof A, Hamm C, Rasoul S, Guptha S, Paolini J, ten Berg J. Ongoing tirofiban in myocardial infarction evaluation (On-TIME) 2 trial: rationale and study design. EUROINTERVENTION 2007; 3:371-80. [DOI: 10.4244/eijv3i3a67] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Rasoul S, de Boer MJ, Suryapranata H, Hoorntje JCA, Gosselink ATM, Zijlstra F, Ottervanger JP, Dambrink JHE, van 't Hof AWJ. Circumflex artery-related acute myocardial infarction: limited ECG abnormalities but poor outcome. Neth Heart J 2007; 15:286-90. [PMID: 18030315 PMCID: PMC1995098 DOI: 10.1007/bf03086001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Circumflex (CX) artery-related myocardial infarction (MI) is less well represented in trials on ST-elevation acute myocardial infarction (STEMI), most often due to the absence of significant ST-segment elevation, and therefore the outcome of these patients is less well known. We aimed to compare the outcome of patients with CX versus right coronary artery (RCA) related STEMI in a large cohort of patients treated with primary angioplasty. METHODS A total of 1683 consecutive patients with STEMI were studied. Patients who lacked STsegment elevation were also included if they had persistent chest pain with signs of ischaemia or regional wall motion abnormalities on echocardiography. Coronary angioplasty was performed according to standard procedures. After the intervention, all patients received aspirin and clopidogrel or ticlopidine. RESULTS The infarct-related vessel was the CX in 229 patients (14%) and the RCA in 600 patients (36%). No differences in baseline characteristics were present. Mean extent of ST-segment elevation or deviation was significantly higher in patients with the RCA as infarct-related vessel. Enzymatic infarct size was significantly higher in the CXrelated MI (1338+/-1117 IU/l vs. 1806+/-1498 IU/l, p<0.001). Left ventricular ejection fraction <45% was more often present in patients with CXrelated MI (37 vs. 26%, p<0.01). Both short- and long-term mortality were significantly higher in the CX-related MI. CONCLUSION This study emphasises the fact that CX-related infarction has a worse prognosis compared with RCA-related infarction. (Neth Heart J 2007;15:286-90.).
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Affiliation(s)
- S Rasoul
- University Medical Centre Groningen, University of Groningen, the Netherlands
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