Clinical experience with primary percutaneous transluminal coronary angioplasty compared with alteplase (recombinant tissue-type plasminogen activator) in patients with acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2)

Complete Revascularization in Patients Undergoing a Pharmacoinvasive Strategy for ST-Segment-Elevation Myocardial Infarction: Insights From the COMPLETE Trial

[Figure: see text].

Multivessel Revascularization in Shock and High-Risk Percutaneous Coronary Intervention

This review explores the usefulness of multivessel revascularization with percutaneous coronary intervention in patients with multivessel obstructive coronary artery disease (CAD) presenting with and without cardiogenic shock. We also evaluate the literature regarding complete versus incomplete revascularization for patients with cardiogenic shock, acute coronary syndromes, and stable coronary artery disease.

Primary percutaneous coronary intervention in octogenarians

BACKGROUND

Limited data are available on the outcome of primary percutaneous coronary intervention (PCI) in octogenarian patients, as the elderly are under-represented in randomized trials. This study aims to provide insights on clinical characteristics, management and outcome of the elderly and very elderly presenting with STEMI.

METHODS

2225 STEMI patients ≥70years old (mean age 76.8±5.1years and 53.8% men) were admitted into the network of the ISACS-TC registry. Of these patients, 72.8% were ≥70 to 79years old (elderly) and 27.2% were ≥80years old (very-elderly). The primary end-point was 30-day mortality.

RESULTS

Thirty-day mortality rates were 13.4% in the elderly and 23.9% in the very-elderly. Primary PCI decreased the unadjusted risk of death both in the elderly (OR: 0.32, 95% CI: 0.24-0.43) and very-elderly patients (OR: 0.45, 95% CI 0.30-0.68), without significant difference between groups. In the very-elderly hypertension and Killip class ≥2 were the only independent factors associated with mortality; whereas in the elderly female gender, prior stroke, chronic kidney disease and Killip class ≥2 were all factors independently associated with mortality. Factors associated with the lack of use of reperfusion were female gender and atypical chest pain in the very-elderly and in the elderly; in the elderly, however, there were some more factors, namely: history of diabetes, current smoking, prior stroke, Killip class ≥2 and history chronic kidney disease.

CONCLUSIONS

Age is relevant in the prognosis of STEMI, but its importance should not be considered secondary to other major clinical factors. Primary PCI appears to have beneficial effects in the octogenarian STEMI patients.

Impact of cardiac care variation on ST-elevation myocardial infarction outcomes in Malaysia

Developing countries face challenges in providing the best reperfusion strategy for patients with ST-segment elevation myocardial infarction because of limited resources. This causes wide variation in the provision of cardiac care. The aim of this study was to assess the impact of variation in cardiac care provision and reperfusion strategies on patient outcomes in Malaysia. Data from a prospective national registry of acute coronary syndromes were used. Thirty-day all-cause mortality in 4,562 patients with ST-segment elevation myocardial infarctions was assessed by (1) cardiac care provision (specialist vs nonspecialist centers), and (2) primary reperfusion therapy (thrombolysis or primary percutaneous coronary intervention [P-PCI]). All patients were risk adjusted by Thrombolysis In Myocardial Infarction (TIMI) risk score. Thrombolytic therapy was administered to 75% of patients with ST-segment elevation myocardial infarctions (12% prehospital and 63% in-hospital fibrinolytics), 7.6% underwent P-PCI, and the remainder received conservative management. In-hospital acute reperfusion therapy was administered to 68% and 73% of patients at specialist and nonspecialist cardiac care facilities, respectively. Timely reperfusion was low, at 24% versus 31%, respectively, for in-hospital fibrinolysis and 28% for P-PCI. Specialist centers had statistically significantly higher use of evidence-based treatments. The adjusted 30-day mortality rates for in-hospital fibrinolytics and P-PCI were 7% (95% confidence interval 5% to 9%) and 7% (95% confidence interval 3% to 11%), respectively (p = 0.75). In conclusion, variation in cardiac care provision and reperfusion strategy did not adversely affect patient outcomes. However, to further improve cardiac care, increased use of evidence-based resources, improvement in the quality of P-PCI care, and reduction in door-to-reperfusion times should be achieved.

Primary coronary intervention versus thrombolytic therapy in myocardial infarction patients in the Middle East

BACKGROUND

Little is known about predictors and outcome differences of primary percutaneous coronary intervention (PPCI) and thrombolytic therapy (TT) in ST-segment elevation myocardial infarction (STEMI) patients in the Middle East.

OBJECTIVE

To compare predictors as well as in-hospital outcomes of PPCI and TT in STEMI patients in six Middle Eastern countries.

SETTING

Sixty-five hospitals (covering at least 85 % of the population) in Oman, United Arab Emirates, Qatar, Bahrain, Kuwait and Yemen.

METHODS

This was a prospective, multinational, multicentre, observational survey of consecutive acute coronary syndrome patients who were admitted to 65 hospitals during May 8, 2006 to June 6, 2006 and from January 29, 2007 to June 29, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). Analyses were performed using univariate and multivariate statistical techniques.

MAIN OUTCOME MEASURES

Predictors as well as in-hospital outcomes of PPCI and TT in STEMI patients.

RESULTS

Out of 2,155 STEMI patients admitted to hospitals within 12 h of symptoms onset, 92 % received reperfusion (8 % PPCI and 84 % TT). TT use included reteplase (43 %), tenecteplase (30 %), streptokinase (25 %), and alteplase (2 %). Median age of the study cohort was 50 (44-58) years with majority being males (90 %). There were no significant differences in median onset time to presentation between the TT and PPCI groups (130 vs. 120 min; P = 0.422). Median door-to-needle time and door-to-balloon time were 45 min (29-75) and 75 min (58-120), respectively. Predictors of PPCI included prior PCI, hospitals with catheterization laboratory facilities as well as those involved with academia. Multivariate logistic regression model demonstrated that patients that had PPCI were less likely to have recurrent ischemic attacks than those that had TT (odds ratio, 0.18; 95 % CI, 0.06-0.56; P = 0.003).

CONCLUSIONS

The main reperfusion strategy for STEMI patients in the Arab Middle East region is thrombolytic therapy. Predictors of primary percutaneous coronary intervention included prior percutaneous coronary intervention, hospitals with catheterization laboratory facilities as well as those involved with academia. Primary percutaneous coronary intervention resulted in significant reductions in recurrent ischemic events when compared to thrombolytic therapy.

Implications of the mechanical (PCI) vs thrombolytic controversy for ST segment elevation myocardial infarction on the organization of emergency medical services: the Boston EMS experience

With the many advances in rapid reperfusion therapy for management of acute ST segment elevation myocardial infarction (STEMI), there is a need to revisit the current plan for prehospital triage (point of entry). Until recently in Boston, and nationwide, there has been a policy that patients with suspected acute MI were brought to the nearest hospital. Then, if ST segment elevation was present, patients were treated with either thrombolytic therapy or primary percutaneous coronary intervention (PCI). Recent data, however, have shown that with advances in interventional devices, techniques and institutional experience, primary PCI is associated with improved outcomes compared with thrombolytic therapy for all patients with STEMI when provided at expert centers with high institutional volumes, with experienced interventional cardiologists as the operators, and with relatively short time to treatment. We describe the rationale for and the implementation of the Boston EMS STEMI Triage Plan and Treatment Registry. Many of the issues that prompted the implementation of the Boston STEMI plan are relevant to all EMS systems. Among these issues are the accuracy of prehospital identification of STEMI patients, the availability of mechanical reperfusion therapy, the appropriate triage of patients with complicated myocardial infarction or shock, as well as the local consensus regarding strength of the evidence favoring mechanical reperfusion. This article describes the history of the Boston EMS STEMI Triage Plan and Treatment Registry and suggests the need for other EMS systems to develop a systematic approach to patients with STEMI.

In-hospital mortality of elderly patients with acute myocardial infarction: data from the MITRA (Maximal Individual Therapy in Acute Myocardial Infarction) registry

BACKGROUND

Advanced age remains one of the principal determinants of mortality in patients with acute myocardial infarction (AMI).

HYPOTHESIS

The aim of this study was to determine the in-hospital outcome of elderly (> 75 years) patients with AMI who were admitted to hospitals participating in the national MITRA (Maximal Individual Therapy in Acute Myocardial Infarction) registry.

METHODS

MITRA is a prospective, observational German multicenter registry investigating current treatment modalities for patients presenting with AMI. All patients with AMI admitted within 96 h of onset of symptoms were included in the MITRA registry. MITRA was started in June 1994 and ended in January 1997. This registry comprises 6,067 consecutive patients with a mean age of 65 +/- 12 years, of whom 1,430 (17%) were aged > 75 years. Patients were compared with respect to patient characteristics, prehospital delays, early treatment strategies, and clinical outcome.

RESULTS

In the elderly patient population, the prehospital delay was 210 min, which was significantly longer than that for younger patients (155 min, p = 0.001). Although the incidence of potential contraindications for the initiation of thrombolysis was almost equally distributed between the two age groups (8.7 vs. 8.2%, p = NS), elderly patients (> 75 years) received reperfusion therapy less frequently (35.9 vs. 64.6%) than younger patients. Mortality increased with advanced age and was 26.4% for all patients aged > 75 years. If reperfusion therapy was initiated, in-hospital mortality was 21.8 versus 28.9% in patients aged > 75 years (p = 0.001) and 29.4 versus 38.5% in patients aged > 85 years (p = 0.001).

CONCLUSION

In this registry, elderly patients with AMI had a much higher in-hospital mortality than that expected from randomized trials. In MITRA, the mortality reduction with reperfusion therapy was found to be highest in the very elderly patient population.

Acute Coronary Care in the Elderly, Part II

Background— Age is an important determinant of outcomes for patients with acute coronary syndromes. However, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients who would stand to benefit. Limited trial data are available to guide care of older adults, which results in uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age and complex health status.

Methods and Results— Part II of this American Heart Association scientific statement summarizes evidence on presentation and treatment of ST-segment–elevation myocardial infarction in relation to age (<65, 65 to 74, 75 to 84, and ≥85 years). The purpose of this statement is to identify areas in which the evidence is sufficient to guide practice in the elderly and to highlight areas that warrant further study. Treatment-related benefits should rise in an elderly population, yet data to confirm these benefits are limited, and the heterogeneity of older populations increases treatment-associated risks. Elderly patients with ST-segment–elevation myocardial infarction more often have relative and absolute contraindications to reperfusion, so eligibility for reperfusion declines with age, and yet elderly patients are less likely to receive reperfusion even if eligible. Data support a benefit from reperfusion in elderly subgroups up to age 85 years. The selection of reperfusion strategy is determined more by availability, time from presentation, shock, and comorbidity than by age. Additional data are needed on selection and dosing of adjunctive therapies and on complications in the elderly. A “one-size-fits-all” approach to care in the oldest old is not feasible, and ethical issues will remain even in the presence of adequate evidence. Nevertheless, if the contributors to treatment benefits and risks are understood, guideline-recommended care may be applied in a patient-centered manner in the oldest subset of patients.

Conclusions— Few trials have adequately described treatment effects in older patients with ST-segment–elevation myocardial infarction. In the future, absolute and relative risks for efficacy and safety in age subgroups should be reported, and trials should make efforts to enroll the elderly in proportion to their prevalence among the treated population. Outcomes of particular relevance to the older adult, such as quality of life, physical function, and independence, should also be evaluated, and geriatric conditions unique to this age group, such as frailty and cognitive impairment, should be considered for their influence on care and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed within the health context of the elderly patient.

Thrombolysis Followed by Early Revascularization: An Effective Reperfusion Strategy in Real World Patients with ST-Elevation Myocardial Infarction

BACKGROUND

Several trials suggested superiority of primary percutaneous coronary intervention (PPCI) angioplasty over thrombolysis in patients with ST-elevation myocardial infarction (STEMI), but many trials were characterized by low rates of early revascularization in patients treated with initial thrombolysis. We tested the hypothesis that in patients with hemodynamically stable STEMI, initial thrombolysis followed by an active early rescue/definitive revascularization strategy could achieve salutary short- and long-term outcomes.

METHODS

A prospective registry documented all 212 STEMI patients who received initial thrombolytic therapy over a 2-year period in a single medical center. Median patient age was 58 (range: 29-92) years, 47 (22%) patients were aged >70 years and 18 (8%) >80 years. Fifty-two (25%) patients underwent rescue angioplasty <6 h after thrombolysis for inadequate clinical reperfusion. In 194/212 (92%) patients, coronary angiography was performed during initial hospitalization, PCI in 168 (79%), and coronary bypass surgery in 18 (8%).

RESULTS

Thirty-day mortality was 4.7% and 1-year mortality 6.7%. Mortality was not related to diabetes mellitus, hypertension, anterior infarction location, fibrin-specific thrombolytic drug or rescue PCI. By multivariate analysis, in-hospital definitive angiography/revascularization (p < 0.0001) and TIMI risk score >3 on admission (p < 0.01) were significant independent predictors of both 30 day and 12 month outcome.

CONCLUSIONS

Initial thrombolysis was useful and effective in real-world STEMI patients when coupled with an aggressive policy of rescue angioplasty and early in-hospital revascularization. Outcomes compared favorably with those reported for PPCI trials. The adverse prognosis in older patients with higher TIMI risk score suggests that in those patients alternative initial treatment strategies such as PPCI should be considered.

Characteristics and outcome of patients with ST-elevation infarction in relation to whether they received thrombolysis or underwent acute coronary angiography: are we selecting the right patients for coronary angiography?

BACKGROUND

During the last decade, there has been an on-going debate with regard to whether percutaneous coronary intervention (PCI) or thrombolysis should be preferred in patients with ST-elevation acute myocardial infarction (AMI). Some studies clearly advocate PCI, while others do not.

HYPOTHESIS

The study aimed to describe the characteristics and to evaluate outcome of patients with suspected ST-elevation or left bundle-branch block infarction in relation to whether they received thrombolysis or had an acute coronary angiography aiming at angioplasty.

METHODS

The study included all patients admitted to Sahlgrenska University Hospital in Göteborg, Sweden, with suspected acute myocardial infarction who, during 1995-1999, had ST-elevation or left bundle-branch block on admission electrocardiogram (ECG) requiring either thrombolysis or acute coronary angiography. A retrospective evaluation with a follow-up of 1 year after the intervention was made.

RESULTS

In all, 413 patients had thrombolytic treatment and 400 had acute coronary angiography. The patients who received thrombolysis were older (mean age 70.3 vs. 64.1 years). Mortality during 1 year of follow-up was 20.9% in the thrombolysis group and 16.6% in the angiography group (p = 0.12). Among patients in whom acute coronary angiography was performed, only 85% underwent acute percutaneous coronary intervention (PCI). There was a mortality of 12.1 vs. 41.7% among those who did not undergo acute PCI. Development of reinfarction, stroke, and requirement of rehospitalization was similar regardless of type of initial intervention. The thrombolysis group more frequently required new coronary angiography (36.9 vs. 20.6%; p<0.0001) and new PCI (17.8 vs. 11.9%; p = 0.01). Despite this, after 1 year symptoms of angina pectoris were observed in 27% of patients in the thrombolysis group and in only 14% of those in the angiography group (p = 0.0002).

CONCLUSION

In a Swedish university hospital with a high volume of coronary angioplasty procedures, we found no significant difference in mortality between patients who had thrombolysis and those who underwent acute coronary angiography. However, requirement of revascularization and symptoms of angina pectoris 1 year later was considerably less frequent in those who had undergone acute coronary angiography. However, distribution of baseline characteristics was skewed and efforts should be focused on the selection of patients for the different reperfusion strategies.

Acute ischemic heart disease and interventional cardiology: a time for pause

BACKGROUND

A major change has occurred in the last few years in the therapeutic approach to patients presenting with all forms of acute coronary syndromes. Whether or not these patients present initially to tertiary cardiac care centers, they are now routinely referred for early coronary angiography and increasingly undergo percutaneous revascularization. This practice is driven primarily by the angiographic image and technical feasibility. Concomitantly, there has been a decline in expectant or ischemia-guided medical management based on specific clinical presentation, response to initial treatment, and results of noninvasive stratification. This 'tertiarization' of acute coronary care has been fueled by the increasing sophistication of the cardiac armamentarium, the peer-reviewed publication of clinical studies purporting to show the superiority of invasive cardiac interventions, and predominantly supporting (non-peer-reviewed) editorials, newsletters, and opinion pieces.

DISCUSSION

This review presents another perspective, based on a critical reexamination of the evidence. The topics addressed are: reperfusion treatment of ST-elevation myocardial infarction; the indications for invasive intervention following thrombolysis; the role of invasive management in non-ST-elevation myocardial infarction and unstable angina; and cost-effectiveness and real world considerations. A few cases encountered in recent practice in community and tertiary hospitals are presented for illustrative purposes The numerous and far-reaching scientific, economic, and philosophical implications that are a consequence of this marked change in clinical practice as well as healthcare, decisional and conflict of interest issues are explored.

SUMMARY

The weight of evidence does not support the contemporary unfocused broad use of invasive interventional procedures across the spectrum of acute coronary clinical presentations. Excessive and unselective recourse to these procedures has deleterious implications for the organization of cardiac health care and undesirable economic, scientific and intellectual consequences. It is suggested that there is need for a new equilibrium based on more refined clinical risk stratification in the treatment of patients who present with acute coronary syndromes.

Reperfusion strategy for acute myocardial infarction in elderly patients aged 75 to 80 years

The increasing elderly population will influence the treatment policies adopted in cases of acute myocardial infarction. Considering reperfusion therapy in elderly patients with acute myocardial infarction, we compared three strategies, as follows: primary percutaneous coronary intervention (primary PCI: n = 26), facilitated PCI with half the standard dose of mutant tissue-type plasminogen activator (t-PA) (half + PCI: n = 24), and facilitated PCI with a standard dose of mutant t-PA (standard + PCI: n = 15) between patients 75 and 80 years of age. The rate of acquisition of thrombolysis in myocardial infarction (TIMI-3) flow on initial coronary arteriography was significantly lower in the primary PCI group than in the other two groups (7.7% in the primary PCI group vs 60% in the half + PCI and 66.7% in the standard + PCI group). The incidence of hemorrhagic complications including blood transfusion was not significantly different between primary PCI and facilitated PCI. Considering reperfusion therapy in elderly patients with acute myocardial infarction, we concluded that facilitated PCI may be effective in elderly patients aged 75-80 years.

Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients

AIMS

Although outcomes after acute myocardial infarction (AMI) seemed to be superior with primary percutaneous coronary intervention (PPCI) relative to fibrinolysis (FL), the extent to which treatment delay modulates this treatment effect is unclear.

METHODS AND RESULTS

Twenty-five randomized trials (n = 7743) testing the efficacy of PPCI vs. FL were identified in journal articles and abstract listings published between 1990 and 2002. Of these, individual patient data from 22 trials (n = 6763) were pooled, and multi-level logistic regression assessed the relationship among treatment, treatment delay, and 30-day mortality. Treatment delay was divided into 'presentation delay' [symptom onset to randomization; FL: median 143 (IQR: 91-225) min; PPCI: 140 (91-220) min] and hospital-specific 'PCI-related delay' [median time from randomization to PPCI minus median time to FL per hospital; median 55 (IQR: 37-74) min]. PPCI was associated with a significant 37% reduction in 30-day mortality [adjusted OR, 0.63; 95% CI (0.42-0.84)]. Although, there was no heterogeneity in the treatment effect by presentation delay (pBreslow-Day = 0.88), the absolute mortality reduction by PPCI widened over time (1.3% 0-1 h to 4.2% >6 h after symptom onset). When the PCI-related delay was <35 min, the relative (67 vs. 28% pBreslow-Day = 0.004) and absolute (5.4 vs. 2.0%) mortality reduction was significantly higher than those with longer delays.

CONCLUSION

PPCI was associated with significantly lower 30-day mortality relative to FL, regardless of treatment delay. Although logistic and economic constraints challenge the feasibility of 'PPCI-for-all', the benefit of timely treatment underscores the importance of a comprehensive, unified approach to delivery of cardiac care in all AMI patients.

Trends in event rate and case fatality of patients hospitalized with myocardial infarction between 1984 and 2001This paper is one of a selection of papers published in this Special Issue, entitled Young Investigator's Forum

Between 1984 and 1993, prevalence and case fatality of hospitalized acute myocardial infarction (AMI) had declined in the population of Halifax County. We aimed to determine whether these trends continued into the 21st century by investigating patient characteristics, treatment methods, and fatality for hospital admissions of residents of Halifax County, aged 25–74, during 1984–1989 (period 1), 1990–1993 (period 2), and 1998–2001 (period 3) and diagnosed as AMI that were extracted from databases for the Halifax County MONICA and ICONS (Improving Cardiovascular Outcomes in Nova Scotia) Studies. Trends in patient characteristics and treatment methods were assessed by χ2 statistics. Their association with 28-day fatality was determined by logistic regression. Event rate declined during 1984–1993 but not into 1998–2001 (p = 0.206). Compared with 1990–1993, fewer AMI patients during 1998–2001 were ≥55 years (73.3% vs. 69.9%), cigarette smokers (49.8% vs. 42.9%), had a history of myocardial infarction (28.9% vs. 24.9%), and had an admission heart rate >100 (34.8% vs. 17.4%). Additionally, more patients had a history of diabetes (22.5% vs. 28.1%). Case fatality declined progressively over the 3 study time periods (16.6%, 13.1%, and 9.4%, respectively). Changes also occurred in prevalence of Killip class 4 status during admission (20.2%, 10.3%, and 13.3%, respectively), use of thrombolysis (9.0%, 30.9, and 32.6%, respectively), and percutaneous coronary intervention (PCI) (4.3%, 11.2%, and 22.4%, respectively) in the different periods. Significant associations were found between case fatality and patient history of diabetes, history of MI, age, elevated admission heart rate, Killip class 4 impairment, thrombolysis, and PCI. The ICONS registry of hospitalized acute myocardial infarctions was used to compare case fatality during 1998–2001 with that reported by the Halifax County MONICA Project for 1984–1993. Whereas the population rate of myocardial infarctions had declined between 1984–1993 but not subsequently, case fatality declined significantly throughout the study period. The continued decline in case fatality is likely explained by changes in patient profile on presentation and medical therapies, including the increased use of thrombolysis and PCI.

[Prehospital management of acute myocardial infarction. Data from a consecutive cohort of 115 patients in a French region in 2002]

The treatment of acute myocardial infarction is in evolution. Several strategies are utilized ranging from thrombolysis to percutaneous angioplasty (PCI), and the combination of both treatments; the latter providing an interesting compromise between treatment delay and efficiency of early myocardial reperfusion. We reviewed the early treatment strategies of acute myocardial infarctions undertaken by Samu in region 6 (south west of France) in 2002. Of a cohort of 115 patients, 83 patients (72.1%) had a revascularisation strategy: 56 (48.7%) had a primary PCI, and 27 (23.4%) had thrombolysis (92.6% being performed in the prehospital treatment). In those undergoing thrombolysis, 13 patients (48%) had ongoing features of ischaemia; excluding 4 patients who died during transport, all had a PCI at the admission in hospital. For the 14 patients with successful thrombolysis, 5 had facilitated PCI at the admission, 8 had a delayed angioplasty and 1 patient did not have angiography. Although the number of patients receiving thrombolysis in this study was small, this treatment was begun 62 minutes before primary PCI. There are important intra and extra hospital delays to the commencement of PCI. The easy utility of thrombolysis together with the potential to PCI argue in favour for a strategy of prehospital thrombolysis associated with a facilitated angioplasty.

Coronary stenting and abciximab in primary angioplasty for ST-segment-elevation myocardial infarction

Advances in anti-platelet therapy and improvement of stent deployment techniques have improved the safety and efficacy of stenting in the setting of ST-segment-elevation myocardial infarction (STEMI). However, in randomized trials, routine coronary stenting does not reduce mortality and re-infarction, compared to balloon angioplasty. Further, the benefits in target vessel revascularization seem to be reduced when applied to unselected patients with STEMI. Direct stenting represents an attractive strategy with potential benefits in terms of myocardial perfusion. Future large randomized trials are needed to evaluate whether this strategy has a significant impact on outcome, and to provide a cost-benefit analysis of the unrestricted use of drug-eluting stents in this high-risk subset of patients. The additional use of abciximab reduces mortality in primary angioplasty. Since the feasibility of long-distance transportation has been shown in several randomized trials, early pharmacological pre-treatment may confer further advantages by early recanalization and shorter ischaemic time, particularly in high-risk patients. Further randomized trials are needed to clarify the potential benefits from early abciximab administration and the potential role of small molecules in primary angioplasty for STEMI.

[Acute coronary syndrome in the prehospital phase]

Cardiovascular diseases are the number one cause of death in Germany. In 2002 about 70,000 people died of acute myocardial infarction (AMI) and of these 37% died before arrival at hospital which underlines the relevance of adequate prehospital care. The generic term acute coronary syndrome (ACS) was introduced because a single pathomechanism accounts for the different forms and comprises unstable angina pectoris (iAP), non-ST-elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI) and sudden cardiac death (SCD). Characteristic features are retrosternal pain, vegetative symptoms and radiation of pain into the adjoining regions. Further differentiation can only be achieved by the 12-lead ECG, as cardiac-specific enzymes do not play a role in prehospital decisions. Prehospital delays should be avoided, history and physical examination should be brief but focused, vital parameters should be assessed and monitored. Basic treatment for ACS should comprise inhalative oxygen, nitrates, morphine, aspirin and beta-blockers. If STEMI is diagnosed, patients with symptoms <12 h should undergo fibrinolytic therapy unless there is primary percutaneous coronary intervention (PCI) available within 90 min or if contraindicated. Heparin should be given to patients with STEMI depending on the choice of fibrinolytic agent, it otherwise results in a higher risk of bleeding, but in patients with iAP or NSTEMI it reduces mortality. All patients must be accompanied by the emergency physician during transportation and should be brought to a hospital with primary PCI, especially those with complicated ACS. Treatment of complications depends largely on the type, persistence and severity.

Overview of contemporary reperfusion strategies in acute ST-elevation myocardial infarction

The rupture of an atherosclerotic plaque in an epicardial coronary artery with subsequent occlusive coronary thrombosis has been established as the decisive event in the pathogenesis of an acute coronary syndrome, which encompasses the clinical entities of unstable angina, non-ST- and ST-elevation myocardial infarction. This article focuses on contemporary treatment strategies for patients with acute ST-elevation myocardial infarction and reviews the role of pharmacologic thrombolysis and mechanical reperfusion by percutaneous transluminal approaches. Statements of the latest guidelines for the treatment of ST-elevation myocardial infarction are included, as well as some recently distributed information not covered by the guideline publications. Finally, some future perspectives for the treatment of acute ST-elevation myocardial infarction are outlined.

Safety of Abciximab Administration During PCI of Patients with Previous Stroke

OBJECTIVES

To examine the frequency of cerebrovascular complications among patients receiving abciximab (AB) undergoing PCI with prior intracranial hemorrhage (ICH) or recent (< 2 years) ischemic strokes.

BACKGROUND

AB improves clinical outcomes in high-risk patients undergoing percutaneous coronary intervention (PCI); however, the safety of AB in patients with prior stroke has not been adequately studied.

METHODS

A database review of 7,244 consecutive PCIs, from 7/97 to 10/01, identified 6,190 PCIs performed with AB among which 515 interventions were performed in patients with prior stroke history [ICH or recent ischemic stroke, (n = 101) and remote (> 2 years) ischemic stroke, (n = 414)].

RESULTS

The post-PCI stroke rate was significantly higher in patients with prior stroke (2.06% vs. 0.35%, p < 0.001 for all stroke; 0.38% vs. 0.03%, p = 0.023 for ICH). The incidence of ICH among the AB-treated group was 0.065%; a history of prior stroke did not increase the incidence of ICH in the AB-treated group (0.39% vs. 0.0%, p = ns). Moreover, the post-PCI stroke rate was similar between the prior ICH or recent ischemic stroke-group and remote ischemic stroke-group (2 vs. 1.9%; OR: 1.03; 95% CI: 0.21-4.90; p = ns for all strokes; 2% vs. 1.5%; OR: 1.4; 95% CI: 0.27-6.91; p = ns for ischemic stroke). Importantly, no ICH occurred in patients with recent ischemic or any prior ICH stroke.

CONCLUSIONS

Abciximab, in addition to aspirin, heparin and ADP-inhibitors does not increase the risk of stroke in patients with prior stroke undergoing PCI.

[Long-term follow-up after primary angioplasty: is stenting beneficial?]

BACKGROUND

Primary stenting leads to a better short-term outcome than balloon angioplasty for acute myocardial infarction in randomised trials. However few data are available about the long-term outcome of primary stenting in acute myocardial infarction (AMI).

OBJECTIVES

The aim of this study was to compare the three-year outcome after primary stenting versus balloon angioplasty in patients with acute myocardial infarction.

METHODS

We conducted a retrospective study including 157 patients with AMI in a single center. Patients underwent balloon angioplasty (N = 48) or primary stenting (N = 109) within six hours after the onset of chest pain. We looked at the outcome during three years focusing on global mortality, major adverse cardiac events (MACE), reinterventions and target vessel revascularization (TVR).

RESULTS

The two groups are similar for their baseline characteristics. No difference was noted for in-patient mortality in the balloon angioplasty group and the primary stenting group (2.1 vs 2.8%; P = ns). The three-year mortality was not significantly different in the two groups. Regarding MACE (27.8 vs 31.7; P = 0.95), reinterventions (20.4 vs 24.7%; P = 0.98) and TVR (18.6 vs 17.8%; P = 0.69), both groups were statistically not different.

CONCLUSION

In the long-term patients treated with stent placement have similar rates of MACE, reinterventions or TVR than patients undergoing balloon angioplasty. If few studies noted a benefit in short-term outcomes, primary stenting doesn't improve the prognosis of acute myocardial infarction on long-term follow-up, which is dependent on atherosclerosis.

Primary angioplasty in acute myocardial infarction: Hypothetical estimate of superiority over aspirin or untreated controls

BACKGROUND

Primary percutaneous transluminal coronary angioplasty (PTCA) in the setting of ST-segment-elevation myocardial infarction has been compared with intravenous thrombolysis, but its effects versus no treatment are not known. Knowledge of the effects of PTCA in this setting is useful as a substantial minority of patients do not receive thrombolysis because of contraindications.

METHODS

A hypothetical primary PTCA versus placebo/control odds ratio was computed using a recently described statistical technique that employed the logarithm of the odds ratios of the pooled results of meta-analyses of PTCA versus thrombolysis and thrombolysis versus placebo or controlled trials.

RESULTS

Using data from 30 trials, the synthesized odds ratio for mortality for primary PTCA versus placebo/untreated controls is 0.56 (95% confidence interval [CI]: 0.46 to 0.68; P <0.00001), consistent with a 44% reduction. Primary PTCA and aspirin reduces mortality by 69% versus no aspirin (OR = 0.31; 95% CI: 0.21 to 0.45; P <0.00001). In a high-risk group of otherwise eligible patients with thrombolysis contraindications, the absolute benefit is estimated as 93 per 1000 treated (95% CI: 53 to 132 per 1000 treated). The risk of stroke is reduced with primary PTCA (OR = 0.46; 95% CI: 0.30 to 0.71; P = 0.0004).

CONCLUSION

In this setting, primary PTCA would hypothetically reduce the short-term risk of death by 44%. Despite the use of aggressive antithrombotic regimens, the risk of stroke would also be reduced substantially with primary PTCA.

Reperfusion strategies for acute myocardial infarction in the elderly

The optimal reperfusion strategy in elderly patients with ST-segment elevation myocardial infarction (STEMI) remains a topic of debate. This lack of consensus stems from the exclusion or under-representation of the elderly in clinical trials. This review evaluates the available literature pertaining to reperfusion therapy for the treatment of STEMI in the elderly. We identified all published studies evaluating the effectiveness of thrombolytic therapy, primary percutaneous coronary intervention (PCI), or adjunctive therapies to reperfusion by conducting an electronic search of MEDLINE through December 2003. Meta-analysis of clinical trials suggests a survival benefit of thrombolytic therapy in the elderly with STEMI, whereas some observational studies have raised concerns about the lack of short-term benefit or possibility of harm with thrombolysis. However, most observational studies demonstrate improved intermediate-term survival with thrombolysis. In contrast, multiple clinical trials and observational studies indicate improved survival and low risk of stroke with primary PCI compared with thrombolysis in elderly patients with STEMI. Information on the efficacy of newer antithrombotic agents as adjunct to thrombolysis or primary PCI is scarce. Available data suggest an increased risk of intracerebral bleeding with the combination of a fibrin-specific agent and a glycoprotein IIb/IIIa receptor antagonist in patients >75 years of age. Clearly targeted large-scale clinical trials are needed to evaluate the relative merits of available reperfusion strategies as well as newer antithrombotic adjunctive therapies in the elderly with STEMI.

Reperfusion treatment of ST-elevation acute myocardial infarction

Reperfusion treatment of ST-segment elevation myocardial infarction (STEMI) is one of the medical interventions with the largest potential for saving human lives, independently of age and gender. An attempt to reopen an acutely occluded coronary artery can be done within a wide array of possibilities, from the simple administration of aspirin to the combination of drugs and complex coronary artery interventions. Fibrinolytic drugs and aspirin represent the easiest way to attempt reperfusion and together offer an acceptable compromise between opportunity for treatment and efficacy. Other drugs and the use of invasive revascularization alternatives yield further advantages, and in some high-risk subgroups may be the most rational treatment approach. Beyond investigator's bias and dedication to either form of reperfusion treatment, interventions and/or drugs should be used as needed (and as possible) to increase the overall impact of reperfusion treatment in the community, taking advantage of the best potential of each approach. Most resources have been directed toward the improvement of reperfusion rates with the combination of fibrinolytic and antiplatelet drugs or with angioplasty. These efforts have certainly raised costs, but have not decisively improved clinical outcome nor have they broadened the impact of reperfusion treatment in the community. Indeed, the main shortcoming of reperfusion therapy is that the cohort of untreated patients is still larger than the cohort of treated patients. At a time when mortality of patients with STEMI reaching the hospital and receiving treatment has decreased significantly, the prehospital diagnosis and treatment of STEMI with the objective of enlarging the treated population and shortening the pretreatment delays is likely the best strategy to further reduce mortality. The need for a population approach to treatment of STEMI is even more obvious when considering the expanding patient load that continuously worsens its clinical risk profile, together with the increasing incidence of diabetes, obesity, hypertension, and smoking habits. The target for improving reperfusion treatment of STEMI in the future, and thereby saving more lives, seems now to involve a cultural change and fulfillment of an organizational mission more than an incremental improvement in the current pharmacologic or interventional approach. These epidemiologic and social aspects of contemporary medicine deserve full attention at a time when researchers, clinicians, and health care providers tend to focus primarily on technological advances.

Impact of Prehospital Thrombolysis for Acute Myocardial Infarction on 1-Year Outcome

Background— Limited data are available on the impact of prehospital thrombolysis (PHT) in the “real-world” setting.

Methods and Results— Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction (≤48 hours of symptom onset) in November 2000; 1922 patients (median age, 67 years; 73% men) with ST-segment–elevation infarction were included, of whom 180 (9%) received intravenous thrombolysis before hospital admission (PHT). Patients with PHT were younger than those with in-hospital thrombolysis, primary percutaneous interventions, or no reperfusion therapy. Median time from symptom onset to hospital admission was 3.6 hours for PHT, 3.5 hours for in-hospital lysis, 3.2 hours for primary percutaneous interventions, and 12 hours for no reperfusion therapy. In-hospital death was 3.3% for PHT, 8.0% for in-hospital lysis, 6.7% for primary percutaneous interventions, and 12.2% for no reperfusion therapy. One-year survival was 94%, 89%, 89%, and 79%, respectively. In a multivariate analysis of predictors of 1-year survival, PHT was associated with a 0.49 relative risk of death (95% CI, 0.24 to 1.00; P =0.05). When the analysis was limited to patients receiving reperfusion therapy, the relative risk of death for PHT was 0.52 (95% CI, 0.25 to 1.08; P =0.08). In patients with PHT admitted in ≤3.5 hours, in-hospital mortality was 0% and 1-year survival was 99%.

Conclusions— The 1-year outcome of patients treated with PHT compares favorably with that of patients treated with other modes of reperfusion therapy; this favorable trend persists after multivariate adjustment. Patients with PHT admitted very early have a very high 1-year survival rate.

Effectiveness of primary percutaneous coronary intervention compared with that of thrombolytic therapy in elderly patients with acute myocardial infarction

BACKGROUND

Few data exist from a community-based perspective on the relative effectiveness of primary percutaneous coronary intervention (PCI) as compared with thrombolytic therapy (TT) in elderly patients with ST-elevation myocardial infarction (STEMI), particularly in the current era of coronary stents and newer antithrombotic agents.

METHODS

We evaluated data from patients, aged > or =70 years, with STEMI who were enrolled in the Global Registry of Acute Coronary Events study between April 1999, and September 2002.

RESULTS

Of the 2975 elderly patients eligible for reperfusion therapy, 365 (12.7%) underwent primary PCI and 769 (26.7%) received TT. The median delay from hospital arrival to therapy was 105 minutes for primary PCI and 40 minutes for TT. Inhospital complications for primary PCI versus TT included mortality (13.5% vs 14.8%), reinfarction (1.1% vs 5.7%), composite of death or reinfarction (14.3% vs 18.7%), cardiogenic shock (11.3% vs 11.6%), major bleeding (8.6% vs 5.9%), and stroke (1.1% vs 2.8%). After adjustment for baseline differences and propensity score, patients receiving primary PCI showed a lower rate of reinfarction (odds ratio [OR], 0.15; 95% CI, 0.05-0.44) and mortality (OR, 0.62; 95% CI, 0.39-0.96) and the composite of reinfarction or death (OR, 0.53; 95% CI, 0.35-0.79), with no difference in other outcome measures.

CONCLUSION

Our data suggest that, compared with TT, primary PCI is associated with a decrease in reinfarction and mortality, with no change in other outcome measures, in elderly patients with STEMI. These findings from an observational registry require further confirmation in future randomized clinical trial assessing the optimal reperfusion strategy in the elderly cohort with STEMI.

Global registries for measuring pharmacoeconomic and quality-of-life outcomes: focus on design and data collection, analysis and interpretation

Disease registries have traditionally been vehicles for the collection of clinical data, in most instances following a large number of patients for a long time period in an observational manner, and enhancing our understanding of disease aetiology and epidemiology. However, over recent decades, the potential for additional data collection and analyses to be conducted within the framework of a registry has been recognised and utilised. This is evident by the sheer number of registries that are now referenced in the medical literature, covering a vast array of therapeutic areas and topics much more varied than incidence, prevalence and survival. The opportunity to collect QOL and pharmacoeconomic data has been utilised within the registry framework as more and more countries have increased their demands for such information for regulatory procedures, including pricing and reimbursement decisions. This increased need for information has led to a marked increase in the number of registries undertaken that are primarily sponsored by the pharmaceutical industry. Disease registries offer tremendous opportunities to realise improvements in care. The length of data collection and the large number of patients involved offer some unusual advantages for QOL and health economic analyses; however, these advantages are not yet fully exploited.