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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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Duhin OA, Kalinskaya AI, Rusakovich GI, Anisimova AS, Netylko JE, Polyakov PA, Vasilieva EY, Shpektor AV. The state of platelet and plasma hemostasis as a predictor of coronary blood flow in patients with acute myocardial infarction. KARDIOLOGIIA 2022; 62:31-37. [PMID: 35989627 DOI: 10.18087/cardio.2022.7.n2143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/25/2022] [Indexed: 06/15/2023]
Abstract
Aim To study the relationship of the platelet function and plasma homeostasis with the blood flow in the infarct-related artery (IRA) and with the course of acute myocardial infarction (AMI).Material and methods This study included 93 patients with AMI (75 patients with ST-elevation AMI and 18 patients without ST segment elevation). 63 patients had TIMI 0-1 blood flow in the IRA and 30 patients had TIMI 2-3. Rotational thromboelastometry, impedance aggregometry, the endothelium-dependent vasodilation (EDVD) test, and the thrombodynamics test were performed for all patients. The primary clinical endpoint included the totality of in-hospital complications of AMI, and the secondary endpoint included the totality of out-of-hospital complications of AMI. Major bleedings (BARC 3-5) and minor bleedings (BARC 1-2) were evaluated separately.Results Patients with IRA TIMI 0-1 flow were characterized by a shorter blood clotting time (BCT), larger thrombus size and density, more intense platelet aggregation induced by arachidonic acid and ADP, and lower values of the EDVD test. It was found that the parameters of platelet aggregation induced by arachidonic acid (AUC Asa) in combination with BCT allowed assessment of the severity of IRA blood flow disorder (sensitivity 76 %, specificity 71 %) in patients with AMI, regardless of the presence of ST segment elevation on the ECG. In addition, the incidence of the primary endpoint was greater in patients with IRA TIMI 0-1 flow (41.3% and 16.7%, respectively; p=0.015). In patients with TIMI 2-3 flow in the long-term period of the disease, the incidence of minor bleedings was significantly higher (8.5% and 30.4 %, respectively; p=0.045).Conclusion Compared to patients with preserved blood flow, patients with AMI and IRA TIMI 0-1 flow are characterized by endothelial dysfunction and more intense processes of thrombogenesis and platelet aggregation. It has been shown for the first time that the combination of two simple criteria for assessing hemostasis (AUC Asa; BCT) allows assessment of the degree of IRA blood flow disorder in patients with AMI.
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Affiliation(s)
- O A Duhin
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow; Davydovsky Municipal Clinical Hospital, Moscow
| | - A I Kalinskaya
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow; Davydovsky Municipal Clinical Hospital, Moscow
| | - G I Rusakovich
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow
| | - A S Anisimova
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow
| | - J E Netylko
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow
| | - P A Polyakov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow
| | - E Yu Vasilieva
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow; Davydovsky Municipal Clinical Hospital, Moscow
| | - A V Shpektor
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow
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Alıcı G, Barman HA, Atıcı A, Tuğrul S, Genç Ö, Şahin İ. The Impact of Lesion Complexity and the CHA 2DS 2-VASc Score on Spontaneous Reperfusion in Patients with ST-Segment Elevation Myocardial Infarction. Int J Clin Pract 2022; 2022:8066780. [PMID: 35685511 PMCID: PMC9159176 DOI: 10.1155/2022/8066780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), a patent infarct-related artery (IRA) on initial angiography is defined as spontaneous reperfusion (SR). OBJECTIVE The present study aimed to determine the impact of lesion complexity and the CHA2DS2-VASc score on SR in patients with STEMI. METHODS A total number of 1,641 consecutive patients with STEMI undergoing primary PCI were assessed for this study. Patients were divided into 2 groups, those with SR, SR(+) (n = 239), and those without SR, SR(-) (n = 1402), according to their initial angiography and SR status. CHA2DS2-VASc scores were calculated for all patients. The lesion complexity of coronary artery disease was assessed with the SYNTAX score. RESULTS The CHA2DS2-VASc and SYNTAX scores were significantly lower in the SR(+) group compared to the SR(-) (mean CHA2DS2-VASc, 1.36 ± 0.64 vs. 2.01 ± 0.80, p < 0.001; mean SYNTAX score, 15.51 ± 5.94 vs. 17.08 ± 8.29, p < 0.001). After the multivariate regression analysis, a lower CHA2DS2-VASc (OR = 0.288, p < 0.001), SYNTAX score (OR = 0.920, p=0.007), uric acid (OR = 0.868, p=0.005), CRP (OR = 0.939, p=0.001), BNP (OR = 0.998, p=0.004), and troponin (OR = 0.991, p=0.001) were independent predictors of SR. In-hospital mortality rates were significantly lower in the SR(+) group compared to the SR(-) (0% vs. 6.7%, p < 0.001). CONCLUSION Our study demonstrated that lesion complexity and the CHA2DS2-VASc score are independently associated with spontaneous reperfusion.
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Affiliation(s)
- Gökhan Alıcı
- Okmeydani Training and Research Hospital, Department of Cardiology, Darulaceze Street No:25, Okmeydanı 34384, İstanbul, Turkey
| | - Hasan Ali Barman
- İstanbul University–Cerrahpasa, Institute of Cardiology, İstanbul, Turkey
| | - Adem Atıcı
- İstanbul Medeniyet University, Göztepe Training and Research Hospital, Department of Cardiology, İstanbul 34722, Turkey
| | - Sevil Tuğrul
- Bağcılar Training and Research Hospital, Department of Cardiology, Bağcılar Center, Mimar Sinan Street, Bağcılar, İstanbul 34100, Turkey
| | - Ömer Genç
- Ağrı Training and Research Hospital, Department of Cardiology, Ağrı Center, Ağrı 04200, Turkey
| | - İrfan Şahin
- Bağcılar Training and Research Hospital, Department of Cardiology, Bağcılar Center, Mimar Sinan Street, Bağcılar, İstanbul 34100, Turkey
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Aoun J, Kleiman NS, Goel SS. Diagnosis and Management of Late-presentation ST-elevation Myocardial Infarction and Complications. Interv Cardiol Clin 2021; 10:369-380. [PMID: 34053623 DOI: 10.1016/j.iccl.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The incidence of late presentation of myocardial infarction varies between 8.5% and 40%. Late revascularization of an infarct-related artery may limit infarct size and remodeling, reduce electrical instability, and may provide supplemental blood supply to that area via collaterals. Randomized clinical trials have shown a benefit of revascularization in symptomatic and hemodynamically unstable latecomers. Image stress testing can be beneficial to guide management of asymptomatic late presenters. Higher rates of myocardial infarction complications occur with late presentations, so a high level of suspicion is required for early diagnosis. Surgical repair remains the gold standard for management of mechanical complications.
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Affiliation(s)
- Joe Aoun
- Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Suite 1901, Houston, TX 77030, USA
| | - Neal S Kleiman
- Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Suite 1901, Houston, TX 77030, USA
| | - Sachin S Goel
- Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Suite 1901, Houston, TX 77030, USA.
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Kanji R, Kubica J, Navarese EP, Gorog DA. Endogenous fibrinolysis-Relevance to clinical thrombosis risk assessment. Eur J Clin Invest 2021; 51:e13471. [PMID: 33296082 DOI: 10.1111/eci.13471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/05/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
The development of an obstructive luminal thrombus is pathological and considered a failure of endogenous fibrinolysis. The consequences may be fatal, or result in lasting downstream organ damage. Therefore, assessment of endogenous fibrinolytic status in an individual may identify those at risk of occlusive thrombus formation and provide prognostic information. Arterial thrombi are more platelet rich and more resistant to fibrinolysis than venous thrombi. Several recent studies using global tests of fibrinolysis in patients with acute coronary syndromes (ACS) have shown that despite dual antiplatelet therapy, patients with impaired fibrinolytic status have an increased risk of adverse cardiovascular events, compared with those with effective fibrinolytic function. Such data add significantly to the predictive value of established cardiovascular risk factors and conventional biomarkers. Most data reported have been obtained with the Global Thrombosis Test and the turbidimetric plasma clot lysis assay. A few small studies in patients with ischaemic stroke suggest a similar predictive role of fibrinolytic status assessment in these patients. Studies reporting an association between impaired fibrinolysis and future venous thrombotic events are limited, and in the form of case-control studies. Viscoelastic assays may have a role in the prediction of venous thromboembolic risk. Assays of fibrinolytic function should be used to obtain a more accurate risk of future thrombotic events, particularly in the setting of ACS. The availability of point-of-care tests helps facilitate this and should encourage future studies to assess personalised antithrombotic treatment combinations to optimise fibrinolytic status and reduce thrombosis risk.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano P Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK.,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Stevenage, UK
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Memtsas VP, Arachchillage DRJ, Gorog DA. Role, Laboratory Assessment and Clinical Relevance of Fibrin, Factor XIII and Endogenous Fibrinolysis in Arterial and Venous Thrombosis. Int J Mol Sci 2021; 22:ijms22031472. [PMID: 33540604 PMCID: PMC7867291 DOI: 10.3390/ijms22031472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
Diseases such as myocardial infarction, ischaemic stroke, peripheral vascular disease and venous thromboembolism are major contributors to morbidity and mortality. Procoagulant, anticoagulant and fibrinolytic pathways are finely regulated in healthy individuals and dysregulated procoagulant, anticoagulant and fibrinolytic pathways lead to arterial and venous thrombosis. In this review article, we discuss the (patho)physiological role and laboratory assessment of fibrin, factor XIII and endogenous fibrinolysis, which are key players in the terminal phase of the coagulation cascade and fibrinolysis. Finally, we present the most up-to-date evidence for their involvement in various disease states and assessment of cardiovascular risk.
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Affiliation(s)
- Vassilios P. Memtsas
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB, UK;
| | - Deepa R. J. Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London SW7 2AZ, UK;
- Department of Haematology, Imperial College Healthcare NHS Trust, London W2 1NY, UK
- Department of Haematology, Royal Brompton Hospital, London SW3 6NP, UK
| | - Diana A. Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB, UK;
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire AL10 9AB, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
- Correspondence: ; Tel.: +44-207-0348841
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7
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Hussain M, Kumar R, Ammar A, Alishan S, Muhammad AS, Farooq F, Saghir T, Khan N, Hassan Rizvi SN, Ashraf T. Frequency of Thrombolysis in Myocardial Infarction III Flow in Patients With Primary Percutaneous Coronary Intervention: Not All Culprit Vessels Are Completely Occluded in ST Elevation Myocardial Infarction. Cureus 2020; 12:e12036. [PMID: 33457136 PMCID: PMC7797447 DOI: 10.7759/cureus.12036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background ST elevation myocardial infarction (STEMI) is classically characterized by total occlusion of the culprit coronary artery. However during primary percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) 0 flow is not observed in all patients' culprit arteries in angiographic views. This study was conducted to find out the frequency of TIMI flow in acute STEMI patients in view of the above concept. The aim of this study was to evaluate the frequency of pre-procedural TIMI III flow in those patients who underwent primary PCI for acute STEMI in a public sector hospital in Karachi, Pakistan. Methodology This study is an audit of already saved data in the catheterization laboratory of the National Institute of Cardiovascular Diseases (NICVD), Karachi, that was collected prospectively from January 2016 to December 2018. These data were collected after taking consent from those patients who presented to hospital within 12 hours of symptoms and underwent primary PCI. Data were entered and analyzed on Statistical Package for the Social Sciences (SPSS) version 19 (IBM Corp., Armonk, NY, USA). Results A total of 8018 patients were included in this study who presented with STEMI and underwent primary PCI. Out of them 80.9% were males. Hypertension was the leading risk factor in 54.1% (4340) of patients. TIMI III flow was present in 11.4% of patients before primary PCI, while TIMI 0, I and II flow were present in 57.1%, 15.1%, and 16.3% of patients respectively (p<0.001). Fourteen percent of patients with TIMI III flow were of age group 51 to 60 years. Among those who had TIMI III flow, 11.2% were those with door to balloon time of <90 minutes. In 11% of cases, left anterior descending (LAD) artery had TIMI III flow as compared to other vessels (p<0.001). The length of the lesion was significantly smaller in patients who had TIMI III flow compared to those who had TIMI 0-II flow. Conclusions This study revealed that not all patients with acute STEMI had totally occluded culprit coronary artery but some of them had angiographic TIMI I-III flow in the infarct-related artery. Further studies are needed to find the reason for re-establishment of flow in the culprit vessel in STEMI patients before PCI.
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8
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Wang J, He SY. Clinical and angiographic characteristics of patients with spontaneous reperfusion in ST-segment elevation myocardial infarction. Medicine (Baltimore) 2020; 99:e19267. [PMID: 32150062 PMCID: PMC7478519 DOI: 10.1097/md.0000000000019267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This study aims to investigate the clinical and angiographic characteristics of patients with spontaneous reperfusion in ST-segment elevation myocardial infarction (STEMI).A total of 519 patients with STEMI were enrolled in this study, who underwent primary percutaneous coronary intervention (PCI) treatments at Beijing Anzhen Hospital from January 2015 to December 2018. The patients were divided into 2 groups according to the TIMI flow grade before primary PCI, the non-spontaneous reperfusion group (TIMI flow grade 0-II) and the spontaneous reperfusion group (TIMI flow grade III). The incidence rate, the clinically relevant factors, and the features of the coronary angiographic lesions of spontaneous reperfusion from the 2 groups were recorded and analyzed.There were significant differences between the 2 groups in age, CTnI peak value, high thrombus burden, and locations of lesions in the distant of left anterior descending artery (LAD) (P = .000, .000, .002, .000, and .003, respectively). However, there were no significant differences between the groups in other clinic aspects including gender, hypertension, diabetes mellitus, smoking history, hyperlipemia, angina pectoris history, culprit vessel distribution, lesion distribution in left circumflex artery (LCX) and right coronary artery (RCA), and collateral circulation (P > .05 for all).Compared to the patients without spontaneous reperfusion, patients with spontaneous reperfusion were younger in age, lower in CTnI peak value, and higher in thrombosis burden, with culprit lesions mostly located in the distant of LAD.
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Tiller C, Reindl M, Holzknecht M, Innerhofer L, Wagner M, Lechner I, Mayr A, Klug G, Bauer A, Metzler B, Reinstadler SJ. Relationship between admission Q waves and microvascular injury in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Int J Cardiol 2019; 297:1-7. [PMID: 31629564 DOI: 10.1016/j.ijcard.2019.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/12/2019] [Accepted: 10/03/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Using comprehensive cardiac magnetic resonance (CMR) imaging in patients suffering from ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), we sought to investigate the association of admission Q waves with microvascular injury (microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH)). METHODS This prospective observational study included 195 STEMI patients treated with pPCI. Admission 12-lead electrocardiography was evaluated for the presence of pathological Q waves, defined as a Q wave duration of >30 ms and a depth of >0.1 mV. CMR was performed at 3 (interquartile range: 2-5) days after pPCI to determine infarct characteristics including MVO (late gadolinium enhancement) and IMH (T2* mapping). RESULTS Admission Q waves were observed in 53% of patients (n = 104). These patients had a significantly lower BMI (p = 0.005), more frequent left anterior descending artery as culprit lesion (p = 0.005), were less frequent smokers (p = 0.048) and had higher rates of pre-interventional TIMI flow 0 (p = 0.018). Patients with Q waves showed a significantly larger infarct size (19%vs.12% of left ventricular mass,p < 0.001), lower ejection fraction (49%vs.54%,p = 0.001), worse global strain parameters (all p < 0.005) and more severe microvascular injury (MVO: 68%vs.34%,p < 0.001; IMH: 40%vs.20%,p = 0.002). Q waves remained associated with both MVO (odds ratio: 5.23, 95% confidence interval: 2.58 to 10.58,p < 0.001) and IMH (odds ratio: 3.94, 95% confidence interval: 1.83 to 8.46,p < 0.001) after adjusting for potential confounders (culprit lesion, pre-interventional TIMI flow 0, total ischemia time, ST-segment elevation). CONCLUSIONS Admission Q waves, derived from the readily available ECG, emerged as independent early markers of CMR-determined microvascular injury in STEMI patients undergoing pPCI.
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Affiliation(s)
- Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Lukas Innerhofer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Miriam Wagner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Sebastian Johannes Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
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Doganay B, Okutucu S, Cetin M, Kızıltunc E, Karayigit O, Ozkan C, Kılınckaya MF, Ornek E. Association of Serum Copeptin Levels with Patency of Infarct-Related Arteries in Patients with ST-Segment Elevation Myocardial Infarction. ACTA CARDIOLOGICA SINICA 2019; 35:360-368. [PMID: 31371896 DOI: 10.6515/acs.201907_35(4).20181101a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Copeptin is widely used as a predictor of an adverse prognosis in many clinical conditions. Reduced antegrade coronary flow in an infarct-related artery (IRA) is associated with adverse clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate whether copeptin level on admission was associated with IRA patency in STEMI patients. Methods A total of 88 patients were enrolled into the study and divided into two groups according to TIMI flow grade in the IRA before primary percutaneous coronary intervention. Results White blood cell count (p = 0.015), neutrophils (p = 0.047), N-terminal pro-brain natriuretic peptide (NTproBNP) (p < 0.001), copeptin (p < 0.001) and peak troponin I (p = 0.001) were significantly higher in the occluded IRA group with a significantly lower serum sodium level (p < 0.001). Age- and gender-adjusted multivariate analysis revealed that copeptin (OR = 1.970; p = 0.001), peak troponin I (1.055; p = 0.005) and NTproBNP (OR = 1.003; p = 0.010) were independent predictors of an occluded IRA. A copeptin cut-off value of > 6.8 ng/mL was found to predict an occluded IRA with a sensitivity of 80% and specificity of 100% (area under the curve: 0.917; p < 0.001). Performance ranking of the biomarkers that could predict an occluded IRA showed copeptin > peak troponin I = NTproBNP. Conclusions Copeptin levels were higher in the patients with an occluded IRA and STEMI. Higher levels of copeptin predicted an occluded IRA in the patients with STEMI who were admitted to the emergency department during the first three hours of chest pain.
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Affiliation(s)
- Birsen Doganay
- Department of Cardiology, Numune Education and Research Hospital
| | | | - Mustafa Cetin
- Department of Cardiology, Numune Education and Research Hospital
| | | | - Orhan Karayigit
- Department of Cardiology, Numune Education and Research Hospital
| | - Can Ozkan
- Department of Cardiology, Numune Education and Research Hospital
| | | | - Ender Ornek
- Department of Cardiology, Numune Education and Research Hospital
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11
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Kochar A, Granger CB. Q Waves at Presentation in Patients With ST-Segment-Elevation Myocardial Infarction: An Underappreciated Marker of Risk. Circ Cardiovasc Interv 2019; 10:CIRCINTERVENTIONS.117.006085. [PMID: 29146675 DOI: 10.1161/circinterventions.117.006085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ajar Kochar
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Christopher B Granger
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
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12
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Li J, Zhou Y, Zhang Y, Zheng J. Admission homocysteine is an independent predictor of spontaneous reperfusion and early infarct-related artery patency before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. BMC Cardiovasc Disord 2018; 18:125. [PMID: 29940881 PMCID: PMC6020223 DOI: 10.1186/s12872-018-0868-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/20/2018] [Indexed: 12/25/2022] Open
Abstract
Background Spontaneous reperfusion (SR) and early infarct related artery (IRA) patency before primary percutaneous coronary intervention (PPCI) might bring extra benefit for patients with ST-segment elevation myocardial infarction (STEMI). This study premilinarily screened the independent predictors of SR, and assessed the relationship between SR and plasma homocysteine (HCY). Methods The medical records of 998 patients who were diagnosed as STEMI and underwent emergency coronary angiography were retrospectively studied, SR was defined as achievement of TIMI grade 3 flow in the IRA before PCI. The baseline characteristics, clinical manifestations and hematological variables were compared between SR and NSR group. Optimal cutoff point of HCY was calculated with receiving operating characteristics (ROC) analysis, multivariate logistic regression models were used to identify predictors of SR. Results 229 (22.95%) patients showed angiographic SR. For HCY, the area under the curve was 0.70 (95% CI: 0.63–0.77, P = 0.034), the optimized cut off point was 17.55 μmol/L. Preinfarct angina (95% CI: 1.61–5.65, P = 0.0005), plasma C-reactive protein (CRP) level (95% CI: 0.87–0.99, P = 0.016) and HCY < 17.55 μmol/L (95% CI: 2.43–8.72, P < 0.0001) were found to be independent predictors for SR. Conclusion In patients with STEMI, HCY < 17.55 μmol/L, preinfarct angina and plasma CRP level were independent predictors of SR.
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Affiliation(s)
- Jing Li
- Department of Cardiology, China-Japan Friendship Hospital, No. 2, Yinghua Road, Beijing, 100029, China.
| | - Ying Zhou
- Department of Cardiology, China-Japan Friendship Hospital, No. 2, Yinghua Road, Beijing, 100029, China
| | - Yaowen Zhang
- Medieco Group Co. Ltd, B901 Building No.20 Hepingxiyuan, Beijing, 100029, China
| | - Jingang Zheng
- Department of Cardiology, China-Japan Friendship Hospital, No. 2, Yinghua Road, Beijing, 100029, China
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13
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Li X, Li B, Gao J, Wang Y, Xue S, Jiang D, Hua Q, Li J. Influence of angiographic spontaneous coronary reperfusion on long-term prognosis in patients with ST-segment elevation myocardial infarction. Oncotarget 2017; 8:79767-79774. [PMID: 29108357 PMCID: PMC5668090 DOI: 10.18632/oncotarget.19338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/30/2017] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To explore the influence of angiographic spontaneous coronary reperfusion (SR) on the short- and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI). MATERIALS AND METHODS Consecutive patients diagnosed as STEMI and undergoing emergent coronary angiography from January 2009 to August 2010 in a single center were enrolled. Patients whose initial coronary blood flow met Thrombolysis in Myocardial Infarction (TIMI) grade 3 were regarded as angiographic SR. Others (TIMI grade < 3) were included into the NSR group and subsequently underwent primary percutaneous coronary intervention (PCI). Patients' characteristics and outcomes were compared. RESULTS A total of 207 patients were eligible for analysis. The coincidence rate of patients both with ≥ 70% ST-segment resolution and ≥ 70% relief of chest pain and SR was 100%. Patients in the SR group (n = 38) were younger, had more smokers, with higher level of platelet count, lower blood glucose and uric acid, and more distal culprit lesions, as compared to the NSR group (n = 169). Importantly, patients in the SR group had lower rates of in-hospital events (0 vs. 22.5%, p < 0.001) with less stents placed (1.03 ± 1.05 vs. 1.59 ± 1.17, p = 0.007). Moreover, there were comparable long-term outcomes (2.6% vs. 6.9%, p = 0.302) between the two groups during 41-month follow ups. CONCLUSIONS Angiographic SR is associated with significantly favorable short-term outcomes.
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Affiliation(s)
- Xiaoming Li
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Boyu Li
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jing Gao
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yunfei Wang
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Song Xue
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Dachuan Jiang
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Qi Hua
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jing Li
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
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14
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Fefer P, Beigel R, Atar S, Aronson D, Pollak A, Zahger D, Asher E, Iakobishvili Z, Shlomo N, Alcalai R, Einhorn-Cohen M, Segev A, Goldenberg I, Matetzky S. Outcomes of Patients Presenting With Clinical Indices of Spontaneous Reperfusion in ST-Elevation Acute Coronary Syndrome Undergoing Deferred Angiography. J Am Heart Assoc 2017; 6:JAHA.116.004552. [PMID: 28743786 PMCID: PMC5586258 DOI: 10.1161/jaha.116.004552] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Few data are available regarding the optimal management of ST-elevation myocardial infarction patients with clinically defined spontaneous reperfusion (SR). We report on the characteristics and outcomes of patients with SR in the primary percutaneous coronary intervention era, and assess whether immediate reperfusion can be deferred. METHODS AND RESULTS Data were drawn from a prospective nationwide survey, ACSIS (Acute Coronary Syndrome Israeli Survey). Definition of SR was predefined as both (1) ≥70% reduction in ST-segment elevation on consecutive ECGs and (2) ≥70% resolution of pain. Of 2361 consecutive ST-elevation-acute coronary syndrome patients in Killip class 1, 405 (17%) were not treated with primary reperfusion therapy because of SR. Intervention in SR patients was performed a median of 26 hours after admission. These patients were compared with the 1956 ST-elevation myocardial infarction patients who underwent primary reperfusion with a median door-to-balloon of 66 minutes (interquartile range 38-106). Baseline characteristics were similar except for slightly higher incidence of renal dysfunction and prior angina pectoris in SR patients. Time from symptom onset to medical contact was significantly greater in SR patients. Patients with SR had significantly less in-hospital heart failure (4% versus 11%) and cardiogenic shock (0% versus 2%) (P<0.01 for all). No significant differences were found in in-hospital mortality (1% versus 2%), 30-day major cardiac events (4% versus 4%), and mortality at 30 days (1% versus 2%) and 1 year (4% versus 4%). CONCLUSIONS Patients with clinically defined SR have a favorable prognosis. Deferring immediate intervention seems to be safe in patients with clinical indices of spontaneous reperfusion.
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Affiliation(s)
- Paul Fefer
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Beigel
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Atar
- Division of Cardiology, Galilee Medical Center, Nahariya, Israel
- Affiliated with the Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Doron Aronson
- Department of Cardiology, Rambam Healthcare Campus and the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Arthur Pollak
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel
| | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Elad Asher
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zaza Iakobishvili
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Nir Shlomo
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronny Alcalai
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel
| | - Michal Einhorn-Cohen
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Segev
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Goldenberg
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Sheng F, Chen B, He M, Zhang M, Shen G. Neutrophil to Lymphocyte Ratio Is Related to Electrocardiographic Sign of Spontaneous Reperfusion in Patients with ST-segment Elevation Myocardial Infarction. Arch Med Res 2016; 47:180-5. [PMID: 27344371 DOI: 10.1016/j.arcmed.2016.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS ST-segment resolution ≥70% on consecutive electrocardiograms (ECGs) before administration of definitive reperfusion therapy is considered as an electrocardiographic sign of spontaneous reperfusion (SR) in STEMI patients and it indicates not only the patency of the infarct-related artery (IRA) but also the microvascular and myocardial reperfusion. Neutrophil/lymphocyte (N/L) ratio has been demonstrated to be associated with the patency of the IRA and no-reflow in patients with STEMI before mechanical reperfusion therapy. However, the association between N/L ratio and ST-segment resolution in STEMI patients with SR was not investigated. The aim of this study was to focus on the relation between N/L ratio and ST-segment resolution in STEMI patients with SR. METHODS One hundred sixty two consecutive patients with their first diagnosed STEMI were enrolled in this study. ECGs of all the patients at admission and 1 h later were obtained. According to electrocardiographic sign of SR, the patients were divided into two groups as SR group and non-SR group. Clinical data between two groups were evaluated. RESULTS Patients in SR group had lower neutrophil counts, higher lymphocyte counts, and lower N/L ratio than patients in non-SR group. Moreover, after undertaking primary PCI, patients in SR group had lower peak cTnT value and higher LVEF than patients in non-SR group. Furthermore, N/L ratio was an independent predictor of electrocardiographic sign of SR in patients with STEMI. CONCLUSION N/L ratio, an easily available laboratory data, may be related to microvascular reperfusion in STEMI patients with electrocardiographic sign of SR.
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Affiliation(s)
- Fuqiang Sheng
- Department of Cardiology, Shanghai Songjiang District Central Hospital, Shanghai, China.
| | - Bin Chen
- Department of Cardiology, East Hospital, Affiliated Shanghai 6(th) Renmin Hospital, Shanghai, China
| | - Maorong He
- Department of Cardiology, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Meilin Zhang
- Department of Cardiology, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Guoying Shen
- Department of Cardiology, Shanghai Songjiang District Central Hospital, Shanghai, China
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16
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Okafor ON, Gorog DA. Endogenous Fibrinolysis: An Important Mediator of Thrombus Formation and Cardiovascular Risk. J Am Coll Cardiol 2015; 65:1683-1699. [PMID: 25908074 DOI: 10.1016/j.jacc.2015.02.040] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 11/15/2022]
Abstract
Most acute cardiovascular events are attributable to arterial thrombosis. Plaque rupture or erosion stimulates platelet activation, aggregation, and thrombosis, whilst simultaneously activating enzymatic processes that mediate endogenous fibrinolysis to physiologically maintain vessel patency. Interplay between these pathways determines clinical outcome. If proaggregatory factors predominate, the thrombus may propagate, leading to vessel occlusion. However, if balanced by a healthy fibrinolytic system, thrombosis may not occur or cause lasting occlusion. Despite abundant evidence for the fibrinolytic system regulating thrombosis, it has been overlooked compared with platelet reactivity, partly due to a lack of techniques to measure it. We evaluate evidence for endogenous fibrinolysis in arterial thrombosis and review techniques to assess it, including biomarkers and global assays, such as thromboelastography and the Global Thrombosis Test. Global assays, simultaneously assessing proaggregatory and fibrinolytic pathways, could play a role in risk stratification and in identifying impaired fibrinolysis as a potential target for pharmacological modulation.
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Affiliation(s)
- Osita N Okafor
- East & North Hertfordshire NHS Trust, Hertfordshire, United Kingdom
| | - Diana A Gorog
- East & North Hertfordshire NHS Trust, Hertfordshire, United Kingdom; Vascular Sciences, National Heart & Lung Institute, Imperial College, London, United Kingdom.
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17
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Woo JI, Kil SH, Brough DE, Lee YJ, Lim DJ, Moon SK. Therapeutic potential of adenovirus-mediated delivery of β-defensin 2 for experimental otitis media. Innate Immun 2014; 21:215-24. [PMID: 24842664 DOI: 10.1177/1753425914534002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Otitis media (OM), one of the most prevalent diseases in young children, is clinically important owing to its high incidence in children and its potential impact on language development and motor coordination. OM is the most common reason for the prescription of antibiotics (accounting for 25% of prescriptions) due to its extremely high incidence. A recent increase in antibiotic resistance among OM pathogens is emerging as a major public health concern globally, which led us to consider non-antibiotic approaches for the management of OM. In this study, we evaluated gene transfer of an antimicrobial peptide, human β-defensin 2 (DEFB4), using an adenoviral vector (Ad5 with deletions of E1/E3/E4) as a potential therapeutic approach. We demonstrated that the transduction of human β-defensin 2 induces the production of human β-defensin 2 and suppresses non-typeable Haemophilus influenzae (NTHi) adhesion to human middle ear epithelial cells. Moreover, intratympanic inoculation of Ad-DEFB4 was found to attenuate NTHi-induced middle ear effusions without eliciting a significant immune response. Most importantly, intratympanic inoculation of Ad-DEFB4 appeared to significantly augment clearance of NTHi from middle ear cavity. Collectively, our results suggest that intratympanic gene delivery of antimicrobial molecules may serve as an alternative/adjuvant approach for the management of OM.
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Affiliation(s)
- Jeong-Im Woo
- Department of Head and Neck Surgery, University of California, Los Angeles, CA, USA
| | - Sung-Hee Kil
- Department of Head and Neck Surgery, University of California, Los Angeles, CA, USA
| | | | - Yoo Jin Lee
- Department of Head and Neck Surgery, University of California, Los Angeles, CA, USA
| | - David J Lim
- Department of Head and Neck Surgery, University of California, Los Angeles, CA, USA
| | - Sung K Moon
- Department of Head and Neck Surgery, University of California, Los Angeles, CA, USA
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18
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Zhu J, Zhang T, Xie Q, Zhang J. Effects of Upstream Administration of Tirofiban Before Percutaneous Coronary Intervention on Spontaneous Reperfusion and Clinical Outcomes in Acute ST-Segment Elevation Myocardial Infarction. Angiology 2013; 66:70-8. [PMID: 24327765 DOI: 10.1177/0003319713514290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We assessed the effects of upstream administration of the glycoprotein IIb/IIIa inhibitor tirofiban before percutaneous coronary intervention (PCI) on spontaneous reperfusion (SR) of infarct-related artery (IRA) and the clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The incidence of SR of the IRA was significantly higher in the tirofiban group than in the no-tirofiban group (141 [36.5%] vs 21 [17.2%], P < .001). By multivariate logistic regression analysis, use of tirofiban (odds ratio 2.32, 95% confidence interval 1.25-4.31, P = .008) independently predicted the occurrence of SR. Kaplan-Meier survival analysis demonstrated that major adverse cardiovascular event-free survival was significantly higher in patients treated with tirofiban than in patients without tirofiban at 30-day (log rank = 11.65, P = .001) and 90-day follow-up (log rank = 16.79, P < .001). Upstream administration of tirofiban is significantly associated with increased SR of the IRA and favorable clinical prognosis in patients undergoing PCI for STEMI.
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Affiliation(s)
- Jianbing Zhu
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Tiantian Zhang
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qianqian Xie
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Junfeng Zhang
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
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19
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Prognostic value of plasma fibrinolysis activation markers in cardiovascular disease. J Am Coll Cardiol 2010; 55:2701-9. [PMID: 20538163 DOI: 10.1016/j.jacc.2009.11.095] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 10/26/2009] [Accepted: 11/02/2009] [Indexed: 11/24/2022]
Abstract
The pivotal role of hypoactive endogenous fibrinolysis in the occurrence of thrombotic cardiovascular events is now well-recognized. To evaluate the diagnostic and prognostic role of impaired fibrinolysis, plasma fibrinolysis markers have been investigated in large prospective studies in both healthy individuals and patients with established coronary disease. Antigen and activity levels of components of the fibrinolytic system were measured by immunoassays, which replaced earlier global fibrinolysis tests. This review covers 45 studies in nearly 50,000 subjects, examining the association between plasma markers of fibrinolysis and coronary artery disease, to establish the usefulness of these markers in predicting future cardiovascular events. The predictive value of plasma levels of tissue-type plasminogen activator, platelet activator inhibitor-1, plasmin-antiplasmin complex, D-dimer, thrombin activatable fibrinolysis inhibitor, and lipoprotein(a) for major adverse cardiac events is highly variable and conflicting, especially after adjusting for conventional risk factors, judging from the published data in the last decade. The value of fibrinolysis activity markers is very limited in aiding diagnosis and risk stratification in the individual patient, on the basis of the weak prognostic values obtained in some studies and the lack of power in others. The physiological limitations of such markers in reflecting endogenous fibrinolysis is discussed. The emerging novel global assays of fibrinolysis will require large-scale clinical trials before their prognostic power or superiority to multiple biomarker measurements can be evaluated.
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20
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Cohen M, Boiangiu C, Abidi M. Therapy for ST-segment elevation myocardial infarction patients who present late or are ineligible for reperfusion therapy. J Am Coll Cardiol 2010; 55:1895-906. [PMID: 20430260 DOI: 10.1016/j.jacc.2009.11.087] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 11/18/2009] [Accepted: 11/19/2009] [Indexed: 10/19/2022]
Abstract
Despite the wide contemporary availability of pharmacological and mechanical means of reperfusion, a very significant proportion of ST-segment elevation myocardial infarction (STEMI) patients are still not offered any reperfusion therapy, and some of them are considered "ineligible for reperfusion." Spontaneous reperfusion and contraindications to the use of fibrinolytics and/or mechanical reperfusion methods account only for a small part of these clinical situations. The boundary between "timely" and "late" presentation in STEMI, the appropriateness of percutaneous intervention in patients presenting late after onset of symptoms, and the impact of sex and age on the eligibility and/or choice of reperfusion therapy continue to be challenged by the most recent published data. In the current invasive-driven reperfusion era, if scientific evidence and clinical guidelines are applied diligently, the vast majority of eligible STEMI patients should receive reperfusion therapy. Pharmacological nonlytic therapy of patients with STEMI, regardless of the choice of reperfusion strategy or the absence of it, is clearly defined by the current practice guidelines. Available data suggest that for patients who do not receive any form of reperfusion, anticoagulation therapy with low molecular weight heparin provides a clear additional mortality benefit versus placebo. Fondaparinux as compared with usual care (unfractionated heparin infusion or placebo) significantly reduces the composite of death or myocardial reinfarction without increasing severe bleeding or number of strokes. In the treatment of late-presenting patients with STEMI (beyond the first 12 h after onset of symptoms), clinical evaluation and risk stratification represent the crucial elements helping in decision making between therapeutic interventions.
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Affiliation(s)
- Marc Cohen
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey 07112, USA.
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Saraf S, Christopoulos C, Salha IB, Stott DJ, Gorog DA. Impaired Endogenous Thrombolysis in Acute Coronary Syndrome Patients Predicts Cardiovascular Death and Nonfatal Myocardial Infarction. J Am Coll Cardiol 2010; 55:2107-15. [DOI: 10.1016/j.jacc.2010.01.033] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 12/23/2009] [Accepted: 01/06/2010] [Indexed: 10/19/2022]
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