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Rikken SAOF, Fabris E, Rosenqvist T, Giannitsis E, ten Berg JM, Hamm C, van ‘t Hof A. Prehospital tirofiban increases the rate of disrupted myocardial infarction in patients with ST-segment elevation myocardial infarction: insights from the On-TIME 2 trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:595-601. [PMID: 38845559 PMCID: PMC11350433 DOI: 10.1093/ehjacc/zuae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 08/29/2024]
Abstract
AIMS In patients with ST-segment elevation myocardial infarction (STEMI), prehospital tirofiban significantly improved myocardial reperfusion. However, its impact on the rate of disrupted myocardial infarction (MI), particularly in the context of high-sensitivity cardiac troponin (hs-cTn) assays, is still unclear. METHODS AND RESULTS The On-TIME 2 (Ongoing Tirofiban In Myocardial infarction Evaluation 2) trial randomly assigned STEMI patients to prehospital tirofiban or placebo before transportation to a percutaneous coronary intervention (PCI) centre. In this post hoc analysis, we evaluated STEMI patients that underwent primary PCI and had measured hs-cTn levels. Troponin T levels were collected at 18-24 and 72-96 h after PCI. Disrupted MI was defined as peak hs-cTn T levels ≤ 10 times the upper limit of normal (≤140 ng/L). Out of 786 STEMI patients, 47 (6%) had a disrupted MI. Disrupted MI occurred in 31 of 386 patients (8.0%) in the tirofiban arm and in 16 of 400 patients (4.0%) in the placebo arm (P = 0.026). After multivariate adjustment, prehospital tirofiban remained independently associated with disrupted MI (odds ratio 2.03; 95% confidence interval 1.10-3.87; P = 0.027). None of the patients with disrupted MI died during the 1-year follow-up, compared with a mortality rate of 2.6% among those without disrupted MI. CONCLUSION Among STEMI patients undergoing primary PCI, the use of prehospital tirofiban was independently associated with a higher rate of disrupted MI. These results, highlighting a potential benefit, underscore the need for future research focusing on innovative pre-treatment approaches that may increase the rate of disrupted MI.
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Affiliation(s)
- Sem A O F Rikken
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy
| | - Tobias Rosenqvist
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Center, Heerlen, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands
| | | | - Jurriën M ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center, P. Debyelaan 25 | 6229 HX Maastricht, Locatie: MUMC+, Level 3, Postbus 5800 | 6202 AZ Maastricht, The Netherlands
| | - Christian Hamm
- Department of Cardiology, Kerckhoff Klinik, Bad Nauheim, Germany
| | - Arnoud van ‘t Hof
- Department of Cardiology, Zuyderland Medical Center, Heerlen, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands
- Department of Cardiology, Maastricht University Medical Center, P. Debyelaan 25 | 6229 HX Maastricht, Locatie: MUMC+, Level 3, Postbus 5800 | 6202 AZ Maastricht, The Netherlands
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Rikken SAOF, Bor WL, Selvarajah A, Zheng KL, Hack AP, Gibson CM, Granger CB, Bentur OS, Coller BS, van 't Hof AWJ, Ten Berg JM. Prepercutaneous coronary intervention Zalunfiban dose-response relationship to target vessel blood flow at initial angiogram in st-elevation myocardial infarction - A post hoc analysis of the cel-02 phase IIa study. Am Heart J 2023; 262:75-82. [PMID: 37088164 PMCID: PMC10630984 DOI: 10.1016/j.ahj.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Zalunfiban (RUC-4) is a novel, subcutaneously administered glycoprotein IIb/IIIa inhibitor (GPI) designed for prehospital treatment to initiate reperfusion in the infarct-related artery (IRA) before primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction (STEMI). Since GPIs have been reported to rapidly reperfuse IRAs, we assessed whether there was a dose-dependent relationship between zalunfiban treatment and angiographic reperfusion indices and thrombus grade of the IRA at initial angiogram in patients with STEMI. METHODS This was a post hoc analysis from the open-label Phase IIa study that investigated the pharmacodynamics, pharmacokinetics, and tolerability of three doses of zalunfiban - 0.075, 0.090 and 0.110 mg/kg - in STEMI patients. This analysis explored dose-dependent associations between zalunfiban and three angiographic indices of the IRA, namely coronary and myocardial blood flow and thrombus burden. Zalunfiban was administered in the cardiac catheterization laboratory prior to vascular access, ∼10 to 15 minutes before the initial angiogram. All angiographic data were analyzed by a blinded, independent, core laboratory. RESULTS Twentyfour out of 27 STEMI patients were evaluable for angiographic analysis (0.075 mg/kg [n=7], 0.090 mg/kg [n=9], and 0.110 mg/kg [n=8]). TIMI flow grade 2 or 3 was seen in 1/7 patients receiving zalunfiban at 0.075 mg/kg, in 6/9 patients receiving 0.090 mg/kg, and in 7/8 patients receiving 0.110 mg/kg (ptrend = 0.004). A similar trend was observed based on TIMI flow grade 3. Myocardial perfusion was also related to zalunfiban dose (ptrend = 0.005) as reflected by more frequent TIMI myocardial perfusion grade 3. Consistent with the dose-dependent trends in greater coronary and myocardial perfusion, TIMI thrombus ≥4 grade was inversely related to zalunfiban dose (ptrend = 0.02). CONCLUSION This post hoc analysis found that higher doses of zalunfiban administered in the cardiac catheterization lab prior to vascular access were associated with greater coronary and myocardial perfusion, and lower thrombus burden at initial angiogram in patients with STEMI undergoing primary percutaneous coronary intervention.
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Affiliation(s)
- Sem A O F Rikken
- St. Antonius Hospital, Nieuwegein, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Willem L Bor
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Abi Selvarajah
- Department of Cardiology, Isala Heart Center, Zwolle, The Netherlands
| | - Kai L Zheng
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Amy P Hack
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | - Ohad S Bentur
- Rockefeller University, Allen and Frances Adler Laboratory of Blood and Vascular Biology, New York, NY
| | - Barry S Coller
- Rockefeller University, Allen and Frances Adler Laboratory of Blood and Vascular Biology, New York, NY
| | - Arnoud W J van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Department of Cardiology, MUMC+, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Jurriën M Ten Berg
- St. Antonius Hospital, Nieuwegein, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Department of Cardiology, MUMC+, Maastricht, The Netherlands
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Gehin M, Storey RF, Bernaud C, Dingemanse J. Clinical pharmacology of selatogrel for self-administration by patients with suspected acute myocardial infarction. Expert Opin Drug Metab Toxicol 2023; 19:697-708. [PMID: 37795868 DOI: 10.1080/17425255.2023.2266384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/29/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION P2Y12 receptor antagonists (P2Y12 inhibitors) are well established for the treatment of coronary artery disease. The P2Y12 inhibitors currently commercially available present either pharmacokinetic limitations (due to delayed absorption, bioactivation requirement via CYP enzymes, or need of intravenous administration), pharmacodynamic (PD) limitations (limited % inhibition of platelet aggregation (IPA) or relevant PD interactions) or safety limitations (major bleeding in specific populations). AREAS COVERED Selatogrel, a 2-phenylpyrimidine-4-carboxamide analog, is a potent, reversible, and selective P2Y12 inhibitor administered subcutaneously that is under development for the treatment of acute myocardial infarction (AMI) in patients with a recent history of AMI. In this review, the authors summarize the results from preclinical, phase 1, and phase 2 trials which showed that selatogrel provides rapid, pronounced, and reversible P2Y12 receptor inhibition with a favorable safety profile. EXPERT OPINION These unique characteristics added to the limited potential to interact with co-medications and manageable PD interactions with other P2Y12 inhibitors provide a clear rationale for investigating the benefit of selatogrel as an emergency treatment to improve clinical outcomes in patients with AMI.
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Affiliation(s)
- Martine Gehin
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals, Allschwil, Switzerland
| | - Robert F Storey
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Corine Bernaud
- Department of Clinical Science, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals, Allschwil, Switzerland
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Tian R, Liu R, Zhang J, Li Y, Wei S, Xu F, Li X, Li C. Efficacy and safety of intracoronary versus intravenous tirofiban in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Heliyon 2023; 9:e15842. [PMID: 37180928 PMCID: PMC10172923 DOI: 10.1016/j.heliyon.2023.e15842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Background Effective antiplatelet therapy is critical for patients with ST-segment elevation myocardial infarction (STEMI) and receiving primary percutaneous coronary interventions (PPCI). Intracoronary (IC) and intravenous (IV) administration of tirofiban are commonly used during the procedure of PPCI. However, which is the better administration route of tirofiban have not been fully evaluated. Methods A comprehensive literature search of RCTs that comparing IC with IV tirofiban in STEMI patients undergoing PPCI was conducted, which were published as of May 7, 2022, in PubMed, Embase, Cochrane Library, Web of Science, Scopus and ClinicalTrials.gov. The primary efficacy endpoint was 30-day major adverse cardiovascular events (MACE) and the primary safety endpoint was in-hospital bleeding events. Results This meta-analysis included 9 trials involving 1177 patients. IC tirofiban significantly reduced the incidence of 30-day MACE (RR 0.65, 95% CI: 0.44 to 0.95, P = 0.028) and improved the rate of the thrombolysis in myocardial infarction (TIMI) grade 3 flow in high-dose (25 μg/kg) group (RR = 1.13, 95% CI: 0.99-1.30, P = 0.001), in-hospital (WMD 2.03, 95% CI: 1.03 to 3.02, P < 0.001), and 6-month left ventricular injection fraction (LVEF) (WMD 6.01, 95% CI: 5.02 to 6.99, P < 0.001) compared with IV. There was no significant difference in the incidences of in-hospital bleeding events (RR 0.96, 95% CI: 0.67 to 1.38, P = 0.82) and thrombocytopenia (RR 0.63, 95% CI: 0.26 to 1.57, P = 0.32) between the two groups. Conclusions IC tirofiban significantly improved the incidence of TIMI 3 in the high-dose group, in-hospital and 6-month LVEF, and reduced the 30-day MACE incidence without increasing the risk of bleeding compared with IV.
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Affiliation(s)
- Rui Tian
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Rugang Liu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Jiajun Zhang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yong Li
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Shujian Wei
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xiaoxing Li
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Chuanbao Li
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Rikken SAOF, Selvarajah A, Hermanides RS, Coller BS, Gibson CM, Granger CB, Lapostolle F, Postma S, van de Wetering H, van Vliet RCW, Montalescot G, Ten Berg JM, van 't Hof AWJ. Prehospital treatment with zalunfiban (RUC-4) in patients with ST- elevation myocardial infarction undergoing primary percutaneous coronary intervention: Rationale and design of the CELEBRATE trial. Am Heart J 2023; 258:119-128. [PMID: 36592878 DOI: 10.1016/j.ahj.2022.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/21/2022] [Accepted: 12/17/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND Early and complete restoration of target vessel patency in ST-elevation myocardial infarction (STEMI) is associated with improved outcomes. Oral P2Y12 inhibitors have failed to demonstrate either improved patency or reduced mortality when administered in the prehospital setting. Thus, there is a need for antiplatelet agents that achieve prompt and potent platelet inhibition, and that restore patency in the prehospital setting. Zalunfiban, a novel subcutaneously administered glycoprotein IIb/IIIa inhibitor designed for prehospital administration, has shown to achieve rapid, high-grade platelet inhibition that exceeds that of P2Y12 inhibitors. Whether prehospital administration of zalunfiban can improve clinical outcome is unknown. HYPOTHESIS The present study is designed to assess the hypothesis that a single, prehospital injection of zalunfiban given in the ambulance, in addition to standard-of-care in patients with STEMI with intent to undergo primary percutaneous coronary intervention (PCI) will improve clinical outcome compared to standard-of-care with placebo. STUDY DESIGN The ongoing CELEBRATE trial (NCT04825743) is a phase 3, randomized, double-blinded, placebo-controlled, international trial. Patients with STEMI intended to undergo primary PCI will receive treatment with a single subcutaneous injection containing either zalunfiban dose 1 (0.110 mg/kg), zalunfiban dose 2 (0.130 mg/kg) or placebo, and the study drug will be administered in the ambulance before transportation to the hospital. A target of 2499 patients will be randomly assigned to one of the treatment groups in a 1:1:1 ratio, ie, to have approximately 833 evaluable patients per group. The primary efficacy outcome is a ranked 7-point scale on clinical outcomes. The primary safety outcome is severe or life-threatening bleeding according to the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) criteria. SUMMARY The CELEBRATE trial will assess whether a single prehospital subcutaneous injection of zalunfiban in addition to standard-of-care in patients with STEMI with intent to undergo primary PCI will result in improved clinical outcome.
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Affiliation(s)
- Sem A O F Rikken
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Abi Selvarajah
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | | | - Barry S Coller
- Allen and Frances Adler Laboratory of Blood and Vascular Biology, New York, NY, United States of America
| | - C Michael Gibson
- Boston Clinical Research Institute, Boston, MA, United States of America
| | - Christopher B Granger
- Department of Cardiology, Duke University School of Medicine, Durham, NC, United States of America
| | | | | | - Henri van de Wetering
- Diagram Research, Zwolle, The Netherlands; Regional Emergency Medical Service Ijsselland, The Netherlands
| | | | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, Department of Cardiology, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Jurriën M Ten Berg
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Arnoud W J van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Hospital, Heerlen, The Netherlands; Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands.
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Wang H, Ng QX, Arulanandam S, Tan C, Ong MEH, Feng M. Building a Machine Learning-based Ambulance Dispatch Triage Model for Emergency Medical Services. HEALTH DATA SCIENCE 2023; 3:0008. [PMID: 38487206 PMCID: PMC10880163 DOI: 10.34133/hds.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 02/05/2023] [Indexed: 03/17/2024]
Abstract
Background In charge of dispatching the ambulances, Emergency Medical Services (EMS) call center specialists often have difficulty deciding the acuity of a case given the information they can gather within a limited time. Although there are protocols to guide their decision-making, observed performance can still lack sensitivity and specificity. Machine learning models have been known to capture complex relationships that are subtle, and well-trained data models can yield accurate predictions in a split of a second. Methods In this study, we proposed a proof-of-concept approach to construct a machine learning model to better predict the acuity of emergency cases. We used more than 360,000 structured emergency call center records of cases received by the national emergency call center in Singapore from 2018 to 2020. Features were created using call records, and multiple machine learning models were trained. Results A Random Forest model achieved the best performance, reducing the over-triage rate by an absolute margin of 15% compared to the call center specialists while maintaining a similar level of under-triage rate. Conclusions The model has the potential to be deployed as a decision support tool for dispatchers alongside current protocols to optimize ambulance dispatch triage and the utilization of emergency ambulance resources.
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Affiliation(s)
- Han Wang
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, Singapore
| | | | | | - Colin Tan
- Singapore Civil Defence Force, Singapore
| | - Marcus E. H. Ong
- Health Services Research Centre, Singapore Health Services, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Mengling Feng
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, Singapore
- Institute of Data Science, National University of Singapore, Singapore
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Farag M, Peverelli M, Spinthakis N, Gue YX, Egred M, Gorog DA. Spontaneous Reperfusion in Patients with Transient ST-Elevation Myocardial Infarction-Prevalence, Importance and Approaches to Management. Cardiovasc Drugs Ther 2023; 37:169-180. [PMID: 34245445 DOI: 10.1007/s10557-021-07226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 01/19/2023]
Abstract
Patients with transient ST-elevation myocardial infarction (STEMI) or spontaneous resolution (SpR) of the ST-segment elevation on electrocardiogram could potentially represent a unique group of patients posing a therapeutic management dilemma. In this review, we discuss the potential mechanisms underlying SpR, its relation to clinical outcomes and the proposed management options for patients with transient STEMI with a focus on immediate versus early percutaneous coronary intervention. We performed a structured literature search of PubMed and Cochrane Library databases from inception to December 2020. Studies focused on SpR in patients with acute coronary syndrome were selected. Available data suggest that deferral of angiography and revascularization within 24-48 h in these patients is reasonable and associated with similar or perhaps better outcomes than immediate angiography. Further randomized trials are needed to elucidate the best pharmacological and invasive strategies for this cohort.
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Affiliation(s)
- Mohamed Farag
- Cardiothoracic Department, Freeman Hospital, Newcastle Upon Tyne, UK.
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK.
| | - Marta Peverelli
- Department of Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Nikolaos Spinthakis
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Ying X Gue
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Mohaned Egred
- Cardiothoracic Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Diana A Gorog
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
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8
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Rikken SAOF, Storey RF, Andreotti F, Clemmensen P, Ten Berg JM. Parenteral Antiplatelet Drugs in ST-Elevation Myocardial Infarction: Current Status and Future Directions. Thromb Haemost 2023; 123:150-158. [PMID: 36075236 DOI: 10.1055/s-0042-1753479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Oral inhibitors of the platelet P2Y12 receptor are indispensable in the treatment of ST-elevation myocardial infarction (STEMI), improving outcomes and even reducing mortality in some studies. However, these drugs are limited by delayed absorption and suboptimal platelet inhibition at the time of primary percutaneous coronary intervention. Despite efforts to achieve faster and more sustained platelet inhibition, strategies such as prehospital administration, higher loading doses, and crushed formulations have not led to improved coronary reperfusion. Parenteral glycoprotein IIb/IIIa inhibitors act sooner and are more potent than oral P2Y12 inhibitors, but their use has been limited by the increased risk of major bleeding and thrombocytopenia. Hence, there is a clinical need to refine drugs that deliver rapid, effective, yet safe platelet inhibition in the setting of STEMI. Novel parenteral antiplatelet drugs, such as cangrelor, selatogrel, and zalunfiban, have been recently developed to achieve rapid, potent antiplatelet effects while preserving hemostasis. We provide a description of currently available parenteral antiplatelet agents and of those in clinical development for prehospital administration in STEMI patients.
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Affiliation(s)
- Sem A O F Rikken
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,School for Cardiovascular Diseases, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Peter Clemmensen
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany.,Department of Medicine, Nykøbing F Hospital, Nykøbing Falster, Denmark
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,School for Cardiovascular Diseases, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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Fabris E, Ottervanger JP, Hermanides RS, Berg JM, Sinagra G, Koopmans PC, Giannitsis E, Hamm C, van ‘t Hof AWJ. Effect of early tirofiban administration on N‐terminal pro‐B‐type natriuretic peptide level in patients treated with primary percutaneous coronary intervention. Catheter Cardiovasc Interv 2018; 93:E293-E297. [DOI: 10.1002/ccd.28043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/16/2018] [Accepted: 12/01/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Enrico Fabris
- Department of CardiologyIsala Heart Center Zwolle The Netherlands
- Cardiovascular DepartmentUniversity of Trieste Trieste Italy
| | | | | | - Jurrien M. Berg
- Department of CardiologySt Antonius Hospital Nieuwegein The Netherlands
| | | | | | | | - Christian Hamm
- Department of CardiologyKerckhoff Klinik Bad Nauheim Germany
| | - Arnoud W. J. van ‘t Hof
- Department of CardiologyMaastricht University Medical Center Maastricht The Netherlands
- Department of CardiologyZuyderland Medical Center Heerlen The Netherlands
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Agnic I, Filipovic N, Vukojevic K, Saraga-Babic M, Grkovic I. Isoflurane post-conditioning influences myocardial infarct healing in rats. Biotech Histochem 2018; 93:354-363. [DOI: 10.1080/10520295.2018.1443507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- I Agnic
- Department of Anaesthesiology, University Hospital Split, Split
| | - N Filipovic
- Department of Anatomy, Histology and Embryology, Laboratory for Neurocardiology, University of Split School of Medicine, Split
| | - K Vukojevic
- Department of Anatomy, Histology and Embryology, Laboratory for Neurocardiology, University of Split School of Medicine, Split
- Department of Anatomy, Histology and Embryology, Laboratory for Early Human Development, University of Split School of Medicine, Split, Croatia
| | - M Saraga-Babic
- Department of Anatomy, Histology and Embryology, Laboratory for Early Human Development, University of Split School of Medicine, Split, Croatia
| | - I Grkovic
- Department of Anatomy, Histology and Embryology, Laboratory for Neurocardiology, University of Split School of Medicine, Split
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Bagai A, Goodman SG, Cantor WJ, Vicaut E, Bolognese L, Cequier A, Chettibi M, Hammett CJ, Huber K, Janzon M, Lapostolle F, Lassen JF, Merkely B, Storey RF, Ten Berg JM, Zeymer U, Diallo A, Hamm CW, Tsatsaris A, El Khoury J, Van't Hof AW, Montalescot G. Duration of ischemia and treatment effects of pre- versus in-hospital ticagrelor in patients with ST-segment elevation myocardial infarction: Insights from the ATLANTIC study. Am Heart J 2018; 196:56-64. [PMID: 29421015 DOI: 10.1016/j.ahj.2017.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/27/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Among patients with STEMI in the ATLANTIC study, pre-hospital administration of ticagrelor improved post-PCI ST-segment resolution and 30-day stent thrombosis. We investigated whether this clinical benefit with pre-hospital ticagrelor differs by ischemic duration. METHODS In a post hoc analysis we compared absence of ST-segment resolution post-PCI and stent thrombosis at 30 days between randomized treatment groups (pre- versus in-hospital ticagrelor) stratified by symptom onset to first medical contact (FMC) duration [≤1 hour (n = 773), >1 to ≤3 hours (n = 772), and >3 hours (n = 311)], examining the interaction between randomized treatment strategy and duration of symptom onset to FMC for each outcome. RESULTS Patients presenting later after symptom onset were older, more likely to be female, and have higher baseline risk. Patients with symptom onset to FMC >3 hours had the greatest improvement in post-PCI ST-segment elevation resolution with pre- versus in-hospital ticagrelor (absolute risk difference: ≤1 hour, 2.9% vs. >1 to ≤3 hours, 3.6% vs. >3 hours, 12.2%; adjusted p for interaction = 0.13), while patients with shorter duration of ischemia had greater improvement in stent thrombosis at 30 days with pre- versus in-hospital ticagrelor (absolute risk difference: ≤1 hour, 1.3% vs. >1 hour to ≤3 hours, 0.7% vs. >3 hours, 0.4%; adjusted p for interaction = 0.55). Symptom onset to active ticagrelor administration was independently associated with stent thrombosis at 30 days (adjusted OR 1.89 per 100 minute delay, 95%CI 1.20-2.97, P < .01), but not post-PCI ST-segment resolution (P = .41). CONCLUSIONS The effect of pre-hospital ticagrelor to reduce stent thrombosis was most evident when given early within 3 hours after symptom onset, with delay in ticagrelor administration after symptom onset associated with higher rate of stent thrombosis. These findings re-emphasize the need for early ticagrelor administration in primary PCI treated STEMI patients.
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Affiliation(s)
- Akshay Bagai
- Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada; Canadian Heart Research Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
| | - Eric Vicaut
- ACTION Study Group, Unité de Recherche Clinique, Hôpital Lariboisière (AP-HP), Paris, France
| | - Leonardo Bolognese
- Cardiovascular and Neurological Department, Azienda Ospedaliera Arezzo, Arezzo, Italy
| | - Angel Cequier
- Heart Disease Institute, Hospital Universitario de Bellvitge, University of Barcelona, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Christopher J Hammett
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, and Sigmund Freud Private University, Medical School, Vienna, Austria
| | - Magnus Janzon
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Jens Flensted Lassen
- Department of Cardiology, The Hearth Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Jurriën M Ten Berg
- Department of Cardiology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Abdourahmane Diallo
- ACTION Study Group, Unité de Recherche Clinique, Hôpital Lariboisière (AP-HP), Paris, France; Unité de Recherche Clinique Lariboisière Saint-Louis Hôpital Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | | | | | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
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Postma S, Dambrink JH, Ottervanger JP, Gosselink M, Koopmans P, ten Berg J, Suryapranata H, van ’t Hof A. Early ambulance initiation versus in-hospital initiation of high dose clopidogrel in ST-segment elevation myocardial infarction. Thromb Haemost 2017; 112:606-13. [DOI: 10.1160/th13-11-0951] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/27/2014] [Indexed: 11/05/2022]
Abstract
SummaryPre-hospital infarct diagnosis gives the opportunity to start anti-platelet and anti-thrombotic agents before arrival at the PCI centre. However, more evidence is necessary to demonstrate whether high dose (HD) clopidogrel (600 mg) administered in the ambulance is associated with improved initial patency of the infarct related vessel (IRV) and/or clinical outcome compared to in-hospital initiation of HD clopidogrel. From 2001 until 2009 all consecutive ST-Segment Elevation Myocardial Infarction (STEMI) patients who underwent pre-hospital diagnosis and therapy in the ambulance were prospectively included in our single-centre cohort study. We compared initial patency of the IRV and clinical outcome in patients treated from 2001 until June 2006 (in-hospital HD clopidogrel) with patients treated from July 2006 until 2009 (ambulance HD clopidogrel). A total of 2,475 patients with STEMI were registered; of these 1,110 (44.8%) received in-hospital HD clopidogrel and 1,365 (55.2%) received ambulance HD clopidogrel. Ambulance HD clopidogrel was not independently associated with initial patency (TIMI-2/3-flow pre-PCI (odds ratio: 1.18, 95% confidence interval [CI] 0.96–1.44); however, it was associated with fewer recurrent myocardial infarctions at 30 days (hazard ratio [HR]: 0.45, 95% CI 0.22–0.93) and at one year (HR: 0.45, 95% CI 0.25–0.80). No difference in TIMI 2/3 flow post-PCI, major bleeding, mortality, MACE – and the combination of mortality and recurrent myocardial infarction at 30-days and at one year was present between the two groups. In conclusion, early in-ambulance as compared to in-hospital initiation of HD clopidogrel in STEMI patients did not improve initial patency of the IRV or clinical outcome, except for a reduction of recurrent myocardial infarction. Therefore, early administration of HD clopidogrel seems to have net clinical benefit for these patients .
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13
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Fabris E, Kilic S, Schellings DAAM, ten Berg JM, Kennedy MW, van Houwelingen KG, Giannitsis E, Kolkman E, Ottervanger JP, Hamm C, van’t Hof AWJ. Long-term mortality and prehospital tirofiban treatment in patients with ST elevation myocardial infarction. Heart 2017; 103:1515-1520. [DOI: 10.1136/heartjnl-2017-311181] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 01/28/2023] Open
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14
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Packer M, O'Connor C, McMurray JJV, Wittes J, Abraham WT, Anker SD, Dickstein K, Filippatos G, Holcomb R, Krum H, Maggioni AP, Mebazaa A, Peacock WF, Petrie MC, Ponikowski P, Ruschitzka F, van Veldhuisen DJ, Kowarski LS, Schactman M, Holzmeister J. Effect of Ularitide on Cardiovascular Mortality in Acute Heart Failure. N Engl J Med 2017; 376:1956-1964. [PMID: 28402745 DOI: 10.1056/nejmoa1601895] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with acute heart failure, early intervention with an intravenous vasodilator has been proposed as a therapeutic goal to reduce cardiac-wall stress and, potentially, myocardial injury, thereby favorably affecting patients' long-term prognosis. METHODS In this double-blind trial, we randomly assigned 2157 patients with acute heart failure to receive a continuous intravenous infusion of either ularitide at a dose of 15 ng per kilogram of body weight per minute or matching placebo for 48 hours, in addition to accepted therapy. Treatment was initiated a median of 6 hours after the initial clinical evaluation. The coprimary outcomes were death from cardiovascular causes during a median follow-up of 15 months and a hierarchical composite end point that evaluated the initial 48-hour clinical course. RESULTS Death from cardiovascular causes occurred in 236 patients in the ularitide group and 225 patients in the placebo group (21.7% vs. 21.0%; hazard ratio, 1.03; 96% confidence interval, 0.85 to 1.25; P=0.75). In the intention-to-treat analysis, there was no significant between-group difference with respect to the hierarchical composite outcome. The ularitide group had greater reductions in systolic blood pressure and in levels of N-terminal pro-brain natriuretic peptide than the placebo group. However, changes in cardiac troponin T levels during the infusion did not differ between the two groups in the 55% of patients with paired data. CONCLUSIONS In patients with acute heart failure, ularitide exerted favorable physiological effects (without affecting cardiac troponin levels), but short-term treatment did not affect a clinical composite end point or reduce long-term cardiovascular mortality. (Funded by Cardiorentis; TRUE-AHF ClinicalTrials.gov number, NCT01661634 .).
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Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Christopher O'Connor
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - John J V McMurray
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Janet Wittes
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - William T Abraham
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Stefan D Anker
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Kenneth Dickstein
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Gerasimos Filippatos
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Richard Holcomb
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Henry Krum
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Aldo P Maggioni
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Alexandre Mebazaa
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - W Frank Peacock
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Mark C Petrie
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Piotr Ponikowski
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Frank Ruschitzka
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Dirk J van Veldhuisen
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Lisa S Kowarski
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Mark Schactman
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Johannes Holzmeister
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
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15
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Cortellini G, Romano A, Santucci A, Barbaud A, Bavbek S, Bignardi D, Blanca M, Bonadonna P, Costantino MT, Laguna JJ, Lombardo C, Losappio L, Makowska J, Nakonechna A, Quercia O, Pastorello EA, Patella V, Terreehorst I, Testi S, Cernadas JR, Dionicio Elera J, Lippolis D, Voltolini S, Grosseto D. Clinical approach on challenge and desensitization procedures with aspirin in patients with ischemic heart disease and nonsteroidal anti-inflammatory drug hypersensitivity. Allergy 2017; 72:498-506. [PMID: 27732743 DOI: 10.1111/all.13068] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hypersensitivity to acetylsalicylic acid (ASA) constitutes a serious problem for subjects with coronary artery disease. In such subjects, physicians have to choose the more appropriate procedure between challenge and desensitization. As the literature on this issue is sparse, this study aimed to establish in these subjects clinical criteria for eligibility for an ASA challenge and/or desensitization. METHODS Collection and analysis of data on ASA challenges and desensitizations from 10 allergy centers, as well as consensus among the related physicians and an expert panel. RESULTS Altogether, 310 subjects were assessed; 217 had histories of urticaria/angioedema, 50 of anaphylaxis, 26 of nonimmediate cutaneous eruptions, and 17 of bronchospasm related to ASA/nonsteroidal anti-inflammatory drugs (NSAID) intake. Specifically, 119 subjects had index reactions to ASA doses lower than 300 mg. Of the 310 subjects, 138 had an acute coronary syndrome (ACS), 101 of whom underwent desensitizations, whereas 172 suffered from a chronic ischemic heart disease (CIHD), 126 of whom underwent challenges. Overall, 163 subjects underwent challenges and 147 subjects underwent desensitizations; 86 of the latter had index reactions to ASA doses of 300 mg or less. Ten subjects reacted to challenges, seven at doses up to 500 mg, three at a cumulative dose of 110 mg. The desensitization failure rate was 1.4%. CONCLUSIONS In patients with stable CIHD and histories of nonsevere hypersensitivity reactions to ASA/NSAIDs, an ASA challenge is advisable. Patients with an ACS and histories of hypersensitivity reactions to ASA, especially following doses lower than 100 mg, should directly undergo desensitization.
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Affiliation(s)
- G. Cortellini
- Internal Medicine and Rheumatology Department; Azienda Sanitaria Romagna; Rimini Hospital; Rimini Italy
| | - A. Romano
- Allergy Unit; Complesso Integrato Columbus; Rome Italy
- IRCCS Oasi Maria S.S.; Troina Italy
| | - A. Santucci
- Internal Medicine and Rheumatology Department; Azienda Sanitaria Romagna; Rimini Hospital; Rimini Italy
| | - A. Barbaud
- Department of Dermatology and Allergology; University Hospital of Nancy; Vandoeuvre-lès-Nancy France
| | - S. Bavbek
- Department of Clinical Immunology and Allergy; School of Medicine; Ankara University; Ankara Turkey
| | - D. Bignardi
- Allergy Unit; San Martino Hospital; Genoa Italy
| | - M. Blanca
- Allergy Service; Carlos Haya Hospital; Malaga Spain
| | - P. Bonadonna
- Allergy Unit; University Hospital of Verona; Verona Italy
| | | | - J. J. Laguna
- Allergy Unit; Hospital de la Cruz Roja; Madrid Spain
| | - C. Lombardo
- Allergy Unit; University Hospital of Verona; Verona Italy
| | - L.M. Losappio
- Allergology and Immunology Unit; Niguarda Ca' Granda Hospital; Milan Italy
| | - J. Makowska
- Department of Rheumatology; Medical University of Lodz; Lodz Poland
| | - A. Nakonechna
- Allergy and Immunology; Clinic Royal Liverpool and Broadgreen University Hospital; Liverpool UK
| | - O. Quercia
- Allergy Unit; Internal Medicine Department; Azienda Sanitaria Romagna; Faenza Italy
| | - E. A. Pastorello
- Allergology and Immunology Unit; Niguarda Ca' Granda Hospital; Milan Italy
| | - V. Patella
- Allergy Unit; Santa Maria della Speranza Hospital; Battipaglia Italy
- Azienda Sanitaria Locale Salerno; Salerno Italy
| | - I. Terreehorst
- Academisch Medisch Centrum; University of Amsterdam; Amsterdam The Netherlands
| | - S. Testi
- Allergy and Clinical Immunology Unit; Azienda Sanitaria di Firenze; San Giovanni di Dio Hospital; Florence Italy
| | - J. R. Cernadas
- Immunoallergy Department; Centro Hospitalar Sao Joao; Porto Portugal
| | | | - D. Lippolis
- Internal Medicine and Rheumatology Department; Azienda Sanitaria Romagna; Rimini Hospital; Rimini Italy
| | | | - D. Grosseto
- Cardiology Unit; Azienda Sanitaria Romagna; Rimini Hospital; Rimini Italy
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16
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Packer M, Holcomb R, Abraham WT, Anker S, Dickstein K, Filippatos G, Krum H, Maggioni AP, McMurray JJV, Mebazaa A, O'Connor C, Peacock F, Ponikowski P, Ruschitzka F, van Veldhuisen DJ, Holzmeister J. Rationale for and design of the TRUE-AHF trial: the effects of ularitide on the short-term clinical course and long-term mortality of patients with acute heart failure. Eur J Heart Fail 2016; 19:673-681. [PMID: 27862700 DOI: 10.1002/ejhf.698] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 12/16/2022] Open
Abstract
The TRUE-AHF is a randomized, double-blind, parallel-group, placebo-controlled trial which is evaluating the effects of a 48-h infusion of ularitide (15 ng/kg/min) on the short- and long-term clinical course of patients with acute heart failure. Noteworthy features of the study include the early enrolment of patients following their initial clinical presentation (within 12 h), and entry blood pressure criteria and thresholds for the adjustment of drug infusion rates, which aim to minimize the risk of hypotension. The trial has two primary endpoints: (i) cardiovascular mortality during long-term follow-up; and (ii) the clinical course of patients during their index hospitalization. Cardiovascular mortality is evaluated in this event-driven trial by following all randomized patients for the occurrence of death until the end of the entire study without truncation at an arbitrarily determined early time point. The clinical course during the index hospitalization is evaluated using the hierarchical clinical composite endpoint, which combines information regarding changes in symptoms and the occurrence of in-hospital worsening heart failure events and death into a single ranked metric that captures interval clinical events and minimizes the likelihood of missing data and confounding due to intensification of background therapy. The design of the TRUE-AHF trial capitalizes on lessons learned from earlier trials and aims to evaluate definitively the potential benefit of ularitide in patients with acute heart failure. TRIAL REGISTRATION NCT01661634.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | | | - Stefan Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon Athens University Hospital, Department of Cardiology, Athens, Greece
| | - Henry Krum
- Monash University, Centre of Cardiovascular Research & Education in Therapeutics, Melbourne, Australia
| | - Aldo P Maggioni
- Centro Studi ANMCO, Fondazione 'per il Tuo cuore' HCF ONLUS, Firenze, Italy
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Alexandre Mebazaa
- University of Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaire Saint Louis Lariboisière, Paris, France
| | | | | | | | | | | | - Johannes Holzmeister
- Cardiology, University Hospital Zurich, Zurich, Switzerland.,Cardiorentis AG, Zug, Switzerland
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17
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Savonitto S, De Luca G, Goldstein P, van T' Hof A, Zeymer U, Morici N, Thiele H, Montalescot G, Bolognese L. Antithrombotic therapy before, during and after emergency angioplasty for ST elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:173-190. [PMID: 26124456 DOI: 10.1177/2048872615590148] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The first three hours after symptom onset hold the maximum potential for myocardial reperfusion and salvage in ST-elevation myocardial infarction (STEMI) patients. During this period timely primary percutaneous coronary intervention (PPCI) or, when PPCI is not promptly feasible, pre-hospital administration of fibrinolyis or a glycoprotein IIb/IIIa-inhibitor (GPI) have been shown to restore coronary patency and reperfusion and even result in myocardial infarction (MI) abortion. On the other hand, oral antiplatelet therapy may not yet guarantee sufficient platelet inhibition. Patients presenting after this golden time have less, if any, benefit from an aggressive antithrombotic treatment prior to PPCI. Antithrombotic treatment during primary angioplasty should be tailored on the basis of the coronary thrombotic burden, vascular approach and the patient's risk of bleeding complications. A GPI-based approach may be favourable in patients presenting early with large MI and high thrombus burden, whereas a bivalirudin-based approach without GPI may be preferred in patients with higher bleeding risk. There are no data to support the use of GPI in bailout conditions. The powerful oral P2Y12 inhibitors, prasugrel and ticagrelor, have been clearly shown to prevent stent thrombosis and recurrent ischaemic events after emergency percutaneous coronary intervention in STEMI patients. Open issues remaining are the treatment of patients with high bleeding risk, such as the elderly and those requiring anticoagulation, as well as the duration of dual antiplatelet therapy after STEMI.
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Affiliation(s)
| | | | | | | | - Uwe Zeymer
- 5 Klinikum Ludwigshafen, Ludwigshafen, Germany
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18
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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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19
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Effects of isoflurane postconditioning on chronic phase of ischemia–reperfusion heart injury in rats. Cardiovasc Pathol 2015; 24:94-101. [DOI: 10.1016/j.carpath.2014.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 09/09/2014] [Accepted: 09/09/2014] [Indexed: 12/12/2022] Open
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20
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De Luca L, Bolognese L, Valgimigli M, Ceravolo R, Danzi GB, Piccaluga E, Rakar S, Cremonesi A, Bovenzi FM, Abbate R, Andreotti F, Bolognese L, Biondi-Zoccai G, Bovenzi FM, Capodanno D, Caporale R, Capranzano P, Carrabba N, Casella G, Cavallini C, Ceravolo R, Colombo P, Conte MR, Cordone S, Cremonesi A, Danzi GB, Del Pinto M, De Luca G, De Luca L, De Servi S, Di Lorenzo E, Di Pasquale G, Esposito G, Farina R, Fiscella A, Formigli D, Galli S, Giudice P, Gonzi G, Greco C, Grieco NB, La Vecchia L, Lazzari M, Lettieri C, Lettino M, Limbruno U, Lupi A, Macchi A, Marini M, Marzilli M, Montinaro A, Musumeci G, Navazio A, Olivari Z, Oltrona Visconti L, Oreglia JA, Ottani F, Parodi G, Pasquetto G, Patti G, Perkan A, Perna GP, Piccaluga E, Piscione F, Prati F, Rakar S, Ravasio R, Ronco F, Rossini R, Rubboli A, Saia F, Sardella G, Satullo G, Savonitto S, Sbarzaglia P, Scorcu G, Signore N, Tarantini G, Terrosu P, Testa L, Tubaro M, Valente S, Valgimigli M, Varbella F, Vatrano M. ANMCO/SICI-GISE paper on antiplatelet therapy in acute coronary syndrome. Eur Heart J Suppl 2014. [DOI: 10.1093/eurheartj/suu030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Prech M, Bartela E, Araszkiewicz A, Janus M, Kutrowska A, Urbanska L, Pyda M, Grajek S. Pre-angiography total ST-segment resolution is not a reliable predictor of an open infarct-related artery. Eur J Intern Med 2014; 25:826-30. [PMID: 25214008 DOI: 10.1016/j.ejim.2014.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 08/04/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND While the cutoffs of predictive value for ST-segment elevations resolution (STSR) following thrombolysis and/or primary PCI were well documented, the impact of pre-angiography STSR has not been established yet. OBJECTIVES The aim of this study is to assess prognostic utility of pre-angiography STSR to predict pre-procedural TIMI flow in the infarct-related artery (IRA) and infarct size in STEMI patients undergoing primary PCI. METHODS A prospective study was performed, including 310 patients, admitted within 12h of symptom onset and who underwent primary PCI. ST-segment elevations were measured in: (1) qualifying ECG, (2) ECG before angiography, and (3) ECG post PCI. STSR was defined as: total (≥70%), partial (between 70% and 30%) and none (<30%). Relationships between pre-angiography STSR, initial TIMI flow and troponin T level (TnT) were analyzed. RESULTS Pre-angiography STSR correlated with initial TIMI flow in the IRA (rS=0.619; p<0.001). Pre-angiography total STSR was observed in 23.2% patients. It was noted in 79.2% of patients with pre-procedural TIMI flow ≥2 and in 20.8% with TIMI flow ≤1 (p<0.001). Although the sensitivity of pre-angiography total STSR to detect pre-procedural TIMI flow ≥2 was 93%, its specificity was only 56% and the likelihood ratio was 2.1. Pre-angiography total STSR was associated with lower peak TnT level (2.2±2.5ng/ml vs. 6.4±5.0ng/ml, p<0.0001) when compared to the remaining patients. CONCLUSIONS 1. Pre-angiography STSR correlates with preprocedural TIMI flow. 2. The sensitivity of pre-angiography total STSR in detection of pre-procedural TIMI flow ≥2 is high, but low specificity of only 56% makes it an unreliable predictor of an open IRA.
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Affiliation(s)
- Marek Prech
- Department of Invasive Cardiology, Kiepury 45, 64-100 Leszno, Poland; I(st) Department of Cardiology, Poznan University of Medical Sciences, Dluga ½, 61-848 Poznan, Poland.
| | - Ewa Bartela
- Department of Invasive Cardiology, Kiepury 45, 64-100 Leszno, Poland.
| | - Aleksander Araszkiewicz
- I(st) Department of Cardiology, Poznan University of Medical Sciences, Dluga ½, 61-848 Poznan, Poland.
| | - Magdalena Janus
- I(st) Department of Cardiology, Poznan University of Medical Sciences, Dluga ½, 61-848 Poznan, Poland
| | - Aleksandra Kutrowska
- I(st) Department of Cardiology, Poznan University of Medical Sciences, Dluga ½, 61-848 Poznan, Poland
| | - Lidia Urbanska
- I(st) Department of Cardiology, Poznan University of Medical Sciences, Dluga ½, 61-848 Poznan, Poland
| | - Malgorzata Pyda
- I(st) Department of Cardiology, Poznan University of Medical Sciences, Dluga ½, 61-848 Poznan, Poland
| | - Stefan Grajek
- I(st) Department of Cardiology, Poznan University of Medical Sciences, Dluga ½, 61-848 Poznan, Poland.
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[Antiplatelet therapy in acute coronary syndrome. Prehospital phase: nothing, aspirin or what?]. Herz 2014; 39:803-7. [PMID: 25315248 DOI: 10.1007/s00059-014-4157-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In most cases of ST segment elevation myocardial infarction (STEMI) a major coronary vessel is occluded by a thrombus. This is why early and effective antiplatelet therapy plays a key role. The current guidelines recommend the administration of dual antiplatelet therapy as early as possible. Despite the lack of convincing clinical evidence, prehospital administration appears reasonable, primarily because of pharmacokinetic considerations. Ticagrelor should be preferentially administered because the largest amount of evidence is available and it appears to be safe. In high-risk patients undergoing transfer to a catheterization laboratory, upstream use of a glycoprotein (GP) IIb/IIIa receptor antagonist (tirofiban) may be considered. Acute coronary syndrome without ST segment elevation (NSTE-ACS) represents a clinically heterogeneous group. Current guidelines recommend that antiplatelet therapy should be initiated as early as possible when the diagnosis of NSTE-ACS is made. If there is high clinical suspicion of NSTE-ACS acetylsalicylic acid (ASA) should be given before hospital admission. In high-risk patients prehospital administration of ticagrelor may be considered.
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Clark DE, Doolittle PC, Winchell RJ, Betensky RA. The effect of hospital care on early survival after penetrating trauma. Inj Epidemiol 2014; 1:24. [PMID: 27747656 PMCID: PMC5005558 DOI: 10.1186/s40621-014-0024-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 08/21/2014] [Indexed: 11/24/2022] Open
Abstract
Background The effectiveness of emergency medical interventions can be best evaluated using time-to-event statistical methods with time-varying covariates (TVC), but this approach is complicated by uncertainty about the actual times of death. We therefore sought to evaluate the effect of hospital intervention on mortality after penetrating trauma using a method that allowed for interval censoring of the precise times of death. Methods Data on persons with penetrating trauma due to interpersonal assault were combined from the 2008 to 2010 National Trauma Data Bank (NTDB) and the 2004 to 2010 National Violent Death Reporting System (NVDRS). Cox and Weibull proportional hazards models for survival time (tSURV) were estimated, with TVC assumed to have constant effects for specified time intervals following hospital arrival. The Weibull model was repeated with tSURV interval-censored to reflect uncertainty about the precise times of death, using an imputation method to accommodate interval censoring along with TVC. Results All models showed that mortality was increased by older age, female sex, firearm mechanism, and injuries involving the head/neck or trunk. Uncensored models showed a paradoxical increase in mortality associated with the first hour in a hospital. The interval-censored model showed that mortality was markedly reduced after admission to a hospital, with a hazard ratio (HR) of 0.68 (95% CI 0.63, 0.73) during the first 30 min declining to a HR of 0.01 after 120 min. Admission to a verified level I trauma center (compared to other hospitals in the NTDB) was associated with a further reduction in mortality, with a HR of 0.93 (95% CI 0.82, 0.97). Conclusions Time-to-event models with TVC and interval censoring can be used to estimate the effect of hospital care on early mortality after penetrating trauma or other acute medical conditions and could potentially be used for interhospital comparisons. Electronic supplementary material The online version of this article (doi:10.1186/s40621-014-0024-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David E Clark
- Department of Surgery, Maine Medical Center, 887 Congress Street, Suite 210, Portland, 04102, ME, USA. .,Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, 04101, ME, USA. .,Tufts University School of Medicine, Boston, 02111, MA, USA. .,Harvard Injury Control Research Center, Harvard School of Public Health, Boston, 02115, MA, USA.
| | - Peter C Doolittle
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, 04101, ME, USA
| | - Robert J Winchell
- Department of Surgery, Maine Medical Center, 887 Congress Street, Suite 210, Portland, 04102, ME, USA.,Tufts University School of Medicine, Boston, 02111, MA, USA
| | - Rebecca A Betensky
- Department of Biostatistics, Harvard School of Public Health, Boston, 02115, MA, USA
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Auffret V, Oger E, Leurent G, Filippi E, Coudert I, Hacot JP, Castellant P, Rialan A, Delaunay R, Rouault G, Druelles P, Boulanger B, Treuil J, Avez B, Bedossa M, Boulmier D, Le Guellec M, Le Breton H. Efficacy of pre-hospital use of glycoprotein IIb/IIIa inhibitors in ST-segment elevation myocardial infarction before mechanical reperfusion in a rapid-transfer network (from the Acute Myocardial Infarction Registry of Brittany). Am J Cardiol 2014; 114:214-23. [PMID: 24878117 DOI: 10.1016/j.amjcard.2014.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 04/15/2014] [Accepted: 04/15/2014] [Indexed: 11/28/2022]
Abstract
Previous studies investigating prehospital use of glycoprotein IIb/IIIa inhibitors (GPIs) in patients with ST-segment elevation myocardial infarction reached conflicting conclusions. The benefit of this strategy in addition to in-ambulance loading of dual-antiplatelet therapy remains controversial. The aim of this study was to analyze data from a prospective registry of patients with ST-segment elevation myocardial infarctions admitted <24 hours after symptom onset (July 2006 to May 2012). A total of 2,052 patients managed in a physician-staffed mobile intensive care unit (MICU)<12 hours after symptom onset and scheduled for primary percutaneous coronary intervention (PPCI) were retrospectively included. Patients who received GPIs in the MICU were compared with those who did not. The primary end point was infarct-related artery patency, defined as pre-PPCI Thrombolysis In Myocardial Infarction (TIMI) flow grade 3. GPIs were administered in the MICU to 737 patients (36%), including 430<2 hours after symptom onset, and 1,315 patients (64%) did not received prehospital GPIs. Pre-PPCI TIMI flow grade 3 rate was lower in patients treated in the MICU (17.2% vs 21.3%, p=0.03) because of patients treated >2 hours after symptom onset, of whom only 12.7% reached the primary end point. There was no significant difference between groups in the rate of in-hospital major adverse cardiac events. In conclusion, prehospital GPI use in patients with ST-segment elevation myocardial infarctions<12 hours after symptom onset scheduled for PPCI neither improved pre-PPCI infarct-related artery patency nor reduced in-hospital major adverse cardiac events.
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Affiliation(s)
- Vincent Auffret
- CHU de Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, Rennes, F-35000, France.
| | - Emmanuel Oger
- CHU de Rennes, Service de Pharmacologie Clinique, Rennes, F-35000, France
| | - Guillaume Leurent
- CHU de Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, Rennes, F-35000, France
| | | | | | | | | | - Antoine Rialan
- CH de Saint Malo, Service de Cardiologie, Saint Malo, F-35400, France
| | - Régis Delaunay
- CH de Saint Brieuc, Service de Cardiologie, Saint Brieuc, F-22000, France
| | - Gilles Rouault
- CH de Quimper, Service de Cardiologie, Quimper, F-29000, France
| | - Philippe Druelles
- Clinique Saint Laurent, Service de Cardiologie, Rennes, F-35000, France
| | | | | | - Bertrand Avez
- CH de Saint Brieuc, SAMU, Saint Brieuc, F-22000, France
| | - Marc Bedossa
- CHU de Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, Rennes, F-35000, France
| | - Dominique Boulmier
- CHU de Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, Rennes, F-35000, France
| | - Marielle Le Guellec
- CHU de Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, Rennes, F-35000, France
| | - Hervé Le Breton
- CHU de Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, Rennes, F-35000, France
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Kommentar zu den Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zur Therapie des akuten Herzinfarkts bei Patienten mit ST-Streckenhebung (STEMI). KARDIOLOGE 2013. [DOI: 10.1007/s12181-013-0530-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clark DE, Winchell RJ, Betensky RA. Estimating the effect of emergency care on early survival after traffic crashes. ACCIDENT; ANALYSIS AND PREVENTION 2013; 60:141-147. [PMID: 24056285 DOI: 10.1016/j.aap.2013.08.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 07/12/2013] [Accepted: 08/22/2013] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Traffic crash mortality is higher in rural areas, but it is unclear whether this is due to greater injury severity, time delays, or Emergency Medical Services (EMS) deficiencies. METHODS Data from 2002-2003 were combined from the Fatality Analysis Reporting System (FARS) and an "expanded version" of the National Automotive Sampling System (NASS) Crashworthiness Data System (CDS). Weighted Cox and Weibull models for survival time (tSURV) were estimated, with time-varying covariates (TVC) having constant effects for specified time intervals following EMS arrival time (tEMS) and hospital arrival time (tHOS). The Weibull model was repeated with tSURV interval-censored to reflect uncertainty about the exact time of death, using an imputation method to accommodate interval censoring along with TVC. RESULTS FARS contained records for 92,718 persons with fatal or incapacitating injuries, and NASS/CDS contained 5517 (weighted population of 642,716) with incapacitating injuries. All models associated mortality with increasing age, male sex, belt nonuse, higher speeds, and vehicle rollover. The interval-censored model associated EMS intervention with a beneficial effect until tEMS+30 min, but not thereafter; hospital intervention was associated with a strongly beneficial effect that increased with time. Rural location was associated with a higher baseline hazard; a 50% reduction in rural prehospital time would theoretically reduce 4-h mortality by about 7%. CONCLUSION Rural/urban disparity in crash mortality is mostly independent of time delays and EMS effects. However, survival models with TVC support clinical intuition of a "golden hour" in EMS care, and the importance of timely transport to a hospital.
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Affiliation(s)
- David E Clark
- Maine Medical Center, Department of Surgery, 887 Congress Street, Suite 210, Portland, ME 04102, United States; Maine Medical Center, Center for Outcomes Research and Evaluation, Portland, ME, United States; Harvard School of Public Health, Harvard Injury Control Research Center, Boston, MA, United States.
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Wong CK. Aborting STEMI: What treatment opportunities may Smart-Phone ECGs give us prior to first medical contact to facilitate primary PCI? Int J Cardiol 2013; 168:5453-5. [DOI: 10.1016/j.ijcard.2013.04.108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 04/04/2013] [Indexed: 11/25/2022]
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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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Pre PCI hospital antithrombotic therapy for ST elevation myocardial infarction: striving for consensus. J Thromb Thrombolysis 2012; 34:20-30. [PMID: 22562147 DOI: 10.1007/s11239-012-0744-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Strong evidence exists in favor of rapid transfer of a patient suffering an ST-elevation myocardial infarction (STEMI) to the nearest hospital with primary percutaneous coronary intervention (PCI) capability, assuming the time from first medical contact to balloon inflation can be achieved in less than 90 min. In many areas, PCI hospitals have successfully collaborated with regional non-PCI hospitals to provide primary PCI for STEMI; however, significant variations exist in how these programs are executed. For example, the pre PCI hospital administration of antithrombotic agents by emergency medical personnel can include aspirin, clopidogrel, unfractionated heparin, low molecular weight heparin, partial or full dose fibrinolytics or combinations thereof. There is little consensus on the optimal cocktail, dose and route of administration. Standardizing the pre PCI antithrombotic regimen across hospital systems may be one approach to improve timely administration of these therapies, and potentially improve STEMI outcomes.
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Zhu TQ, Zhang Q, Qiu JP, Jin HG, Lu L, Shen J, Zhao LP, Zhang RY, Hu J, Yang ZK, Shen WF. Beneficial effects of intracoronary tirofiban bolus administration following upstream intravenous treatment in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: the ICT-AMI study. Int J Cardiol 2011; 165:437-43. [PMID: 21940058 DOI: 10.1016/j.ijcard.2011.08.082] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 07/14/2011] [Accepted: 08/23/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND We investigated whether an additional intracoronary tirofiban bolus administration following upstream intravenous treatment could further improve myocardial reperfusion and clinical outcome in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS A total of 453 eligible STEMI patients were randomly allocated to intracoronary bolus administration of tirofiban (10 μg/kg; n=229) or saline (10 mL; n=224) during primary PCI, followed by intravenous tirofiban infusion (0.15 μg/kg/min) for 24-36 h. Serum levels of P-selectin, vWF, CD40L and serum amyloid A (SAA) in the coronary sinus were measured before and after intracoronary bolus administration. The primary endpoint was ST-segment resolution (STR) at 90 min after the procedure. Second endpoints included corrected TIMI frame count (cTFC), left ventricular volumes and ejection fraction (EF), and major adverse cardiac events (MACE) at 30-day and 6-month follow-up. RESULTS Intracoronary tirofiban administration resulted in a higher rate of completed STR (59.0% vs. 44.6%, P=0.002), lower cTFC (21.6±5.4 vs. 23.7±7.8, P=0.048), and significantly reduced coronary sinus levels of P-selectin, vWF, CD40L and SAA. Patients treated with intracoronary tirofiban had a trend toward less MACE at 30 days (3.1% vs. 6.7%, P=0.072). At 6 months, left ventricular end-systolic volume was smaller, EF was higher and MACE-free survival was improved (96.1% vs. 90.6%, P=0.020) in the intracoronary tirofiban group. CONCLUSIONS An additional intracoronary tirofiban bolus administration following upstream intravenous treatment reduces coronary circulatory platelet activation and inflammatory process, and significantly improves myocardial reperfusion and left ventricular function as well as 6-month MACE-free survival for STEMI patients undergoing primary PCI.
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Affiliation(s)
- Tian Qi Zhu
- Department of Cardiology, Rui Jin Hospital, Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China
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Valgimigli M. AMI on the move. EUROINTERVENTION 2011; 7:415, 417, 419. [PMID: 21764657 DOI: 10.4244/eijv7i4a68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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