Ten-year follow-up of the first megatrial testing thrombolytic therapy in patients with acute myocardial infarction: results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto-1 study. The GISSI Investigators

A randomized trial of expedited intra-arrest transfer versus more extended on-scene resuscitation for refractory out of hospital cardiac arrest: Rationale and design of the EVIDENCE trial

BACKGROUND

Refractory Out of Hospital Cardiac Arrest (r-OHCA) is common and the benefit versus harm of intra-arrest transport of patients to hospital is not clear.

OBJECTIVE

To assess the rate of survival to hospital discharge in adult patients with r-OHCA, initial rhythm pulseless ventricular tachycardia (VT)/ventricular fibrillation (VF) or Pulseless Electrical Activity (PEA) treated with 1 of 2 locally accepted standards of care:1 expedited transport from scene; or2 ongoing advanced life support (ALS) resuscitation on-scene.

HYPOTHESIS

We hypothesize that expedited transport from scene in r-OHCA improves survival with favorable neurological status/outcome.

METHODS/DESIGN

Phase III, multi-center, partially blinded, prospective, intention-to-treat, safety and efficacy clinical trial with contemporaneous registry of patient ineligible for the clinical trial. Eligible patients for inclusion are adults with witnessed r-OHCA; estimated age 18 to 70, assumed medical cause with immediate bystander cardiopulmonary resuscitation (CPR); initial rhythm of VF/pulseless VT, or PEA; no return of spontaneous circulation following 3 shocks and/or 15 minutes of professional on-scene resuscitation; with mechanical CPR available. Two hundred patients will be randomized in a 1:1 ratio to either expedited transport from scene or ongoing ALS at the scene of cardiac arrest.

SETTING

Two urban regions in NSW Australia.

OUTCOMES

Primary: survival to hospital discharge with cerebral performance category (CPC) 1 or 2. Secondary: safety, survival, prognostic factors, use of ECMO supported CPR and functional assessment at hospital discharge and 4 weeks and 6 months, quality of life, healthcare use and cost-effectiveness.

CONCLUSIONS

The EVIDENCE trial will determine the potential risks and benefits of an expedited transport from scene of cardiac arrest.

The Effects of the SARS-CoV-2 Virus on the Cardiovascular System and Coagulation State Leading to Cardiovascular Diseases: A Narrative Review

The novel coronavirus pandemic has led to morbidity and mortality throughout the world. Until now, it is a highly virulent contagion attacking the respiratory system in humans, especially people with chronic diseases and the elderly who are most vulnerable. A majority of afflicted are those suffering from cardiovascular and coronary diseases. In this review article, an attempt has been made to discuss and thoroughly review the mode of therapies that alleviate cardiac complications and complications due to hypercoagulation in patients infected with the SARS-CoV-2 virus. Presently a host of thrombolytic drugs are in use like Prourokinase, Retelapse, RhTNK-tPA and Urokinase. However, thrombolytic therapy, especially if given intravenously, is associated with a serious risk of intracranial haemorrhage, systemic haemorrhage, immunologic complications, hypotension and myocardial rupture. The effects of the SARS-CoV-2 virus upon the cardiovascular system and coagulation state of the body are being closely studied. In connection to the same, clinical prognosis and complications of thrombolytic therapy are being scrutinized. It is noteworthy to mention that myocardial oxygen supply/demand mismatch, direct myocardial cells injury and acute plaque rupture are the multiple mechanisms responsible for acute coronary syndrome and cardiac complications in Covid-19 infection. However, this review has limitations as data available in this context is limited, scattered and heterogenous that questions the reliability of the same. So, more multi-centric studies involving representative populations, carried out meticulously, could further assist in responding better to cardiac complications among Covid-19 patients.

Trends in cardiovascular diseases burden and vascular risk factors in Italy: The Global Burden of Disease study 1990-2017

AIMS

An exhaustive and updated estimation of cardiovascular disease burden and vascular risk factors is still lacking in European countries. This study aims to fill this gap assessing the global Italian cardiovascular disease burden and its changes from 1990 to 2017 and comparing the Italian situation with European countries.

METHODS

All accessible data sources from the 2017 Global Burden of Disease study were used to estimate the cardiovascular disease prevalence, mortality and disability-adjusted life years and cardiovascular disease attributable risk factors burden in Italy from 1990 to 2017. Furthermore, we compared the cardiovascular disease burden within the 28 European Union countries.

RESULTS

Since 1990, we observed a significant decrease of cardiovascular disease burden, particularly in the age-standardised prevalence (-12.7%), mortality rate (-53.8%), and disability-adjusted life years rate (-55.5%). Similar improvements were observed in the majority of European countries. However, we found an increase in all-ages prevalence of cardiovascular diseases from 5.75 m to 7.49 m Italian residents. Cardiovascular diseases still remain the first cause of death (34.8% of total mortality). More than 80% of the cardiovascular disease burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high low density lipoprotein cholesterol, and impaired kidney function.

CONCLUSIONS

Our study shows a decline in cardiovascular mortality and disability-adjusted life years, which reflects the success in reducing disability, premature death and early incidence of cardiovascular diseases. However, the burden of cardiovascular diseases is still high. An approach that includes the cooperation and coordination of all stakeholders of the Italian National Health System is required to further reduce this burden.

Rationale and design of: A Randomized tRial of Expedited transfer to a cardiac arrest center for non-ST elevation out-of-hospital cardiac arrest: The ARREST randomized controlled trial

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a global public health issue. There is wide variation in both regional and inter-hospital survival rates from OHCA and overall survival remains poor at 7%. Regionalization of care into cardiac arrest centers (CAC) improves outcomes following cardiac arrest from ST elevation myocardial infarction (STEMI) through concentration of services and greater provider experience. The International Liaison Committee on Resuscitation (ILCOR) recommends delivery of all post-arrest patients to a CAC, but that randomized controlled trials are necessary in patients without ST elevation (STE).

METHODS/DESIGN

Following completion of a pilot randomized trial to assess safety and feasibility of conducting a large-scale randomized controlled trial in patients following OHCA of presumed cardiac cause without STE, we present the rationale and design of A Randomized tRial of Expedited transfer to a cardiac arrest center for non-ST elevation OHCA (ARREST). In total 860 patients will be enrolled and randomized (1:1) to expedited transfer to CAC (24/7 access to interventional cardiology facilities, cooling and goal-directed therapies) or to the current standard of care, which comprises delivery to the nearest emergency department. Primary outcome is 30-day all-cause mortality and secondary outcomes are 30-day and 3-month neurological status and 3, 6 and 12-month mortality. Patients will be followed up for one year after enrolment.

CONCLUSION

Post-arrest care is time-critical, requires a multi-disciplinary approach and may be more optimally delivered in centers with greater provider experience. This trial would help to demonstrate if regionalization of post-arrest care to CACs reduces mortality in patients without STE, which could dramatically reshape emergency care provision.

Association of Guideline-Based Admission Treatments and Life Expectancy After Myocardial Infarction in Elderly Medicare Beneficiaries

BACKGROUND

Guideline-based admission therapies for acute myocardial infarction (AMI) significantly improve 30-day survival, but little is known about their association with long-term outcomes.

OBJECTIVES

This study evaluated the association of 5 AMI admission therapies (aspirin, beta-blockers, acute reperfusion therapy, door-to-balloon [D2B] time ≤90 min, and time to fibrinolysis ≤30 min) with life expectancy and years of life saved after AMI.

METHODS

We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for AMI, with 17 years of follow-up. Life expectancy and years of life saved after AMI were calculated using Cox proportional hazards regression with extrapolation using exponential models.

RESULTS

Survival for recipients and non-recipients of the 5 guideline-based therapies diverged early after admission and continued to diverge during 17-year follow-up. Receipt of aspirin, beta-blockers, and acute reperfusion therapy on admission was associated with longer life expectancy of 0.78 (standard error [SE]: 0.05), 0.55 (SE: 0.06), and 1.03 (SE: 0.12) years, respectively. Patients receiving primary percutaneous coronary intervention (PCI) within 90 min lived 1.08 (SE: 0.49) years longer than patients with D2B times >90 min, and door-to-needle (D2N) times ≤30 min were associated with 0.55 (SE: 0.12) more years of life. A dose-response relationship was observed between longer D2B and D2N times and shorter life expectancy after AMI.

CONCLUSIONS

Guideline-based therapy for AMI admission is associated with both early and late survival benefits, and results in meaningful gains in life expectancy and large numbers of years of life saved in elderly patients.

Life Expectancy after Myocardial Infarction, According to Hospital Performance

BACKGROUND

Thirty-day risk-standardized mortality rates after acute myocardial infarction are commonly used to evaluate and compare hospital performance. However, it is not known whether differences among hospitals in the early survival of patients with acute myocardial infarction are associated with differences in long-term survival.

METHODS

We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries who were hospitalized for acute myocardial infarction between 1994 and 1996 and who had 17 years of follow-up. We grouped hospitals into five strata that were based on case-mix severity. Within each case-mix stratum, we compared life expectancy among patients admitted to high-performing hospitals with life expectancy among patients admitted to low-performing hospitals. Hospital performance was defined by quintiles of 30-day risk-standardized mortality rates. Cox proportional-hazards models were used to calculate life expectancy.

RESULTS

The study sample included 119,735 patients with acute myocardial infarction who were admitted to 1824 hospitals. Within each case-mix stratum, survival curves of the patients admitted to hospitals in each risk-standardized mortality rate quintile separated within the first 30 days and then remained parallel over 17 years of follow-up. Estimated life expectancy declined as hospital risk-standardized mortality rate quintile increased. On average, patients treated at high-performing hospitals lived between 0.74 and 1.14 years longer, depending on hospital case mix, than patients treated at low-performing hospitals. When 30-day survivors were examined separately, there was no significant difference in unadjusted or adjusted life expectancy across hospital risk-standardized mortality rate quintiles.

CONCLUSIONS

In this study, patients admitted to high-performing hospitals after acute myocardial infarction had longer life expectancies than patients treated in low-performing hospitals. This survival benefit occurred in the first 30 days and persisted over the long term. (Funded by the National Heart, Lung, and Blood Institute and the National Institute of General Medical Sciences Medical Scientist Training Program.).

Spontaneous Rupture of Hepatocellular Carcinoma Mimicking ST-Segment Elevation Myocardial Infarction

BACKGROUND

Several medical conditions that mimic ST-elevation myocardial infarction (STEMI) have been reported previously, but acute abdominal disease mimicking STEMI is rare.

CASE REPORT

We report on a 72-year-old man who presented to the emergency department (ED) with epigastric pain. Meanwhile, STEMI with shock developed. Anticoagulation medication and emergent percutaneous coronary intervention (PCI) were arranged in a timely manner. However, hepatocellular carcinoma (HCC) rupture was the true cause of the ST-segment elevation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report highlights the fact that acute myocardial infarction is not the only cause of ST-segment elevation. HCC rupture should be one of the differential diagnoses.

Long-term survival benefits of thrombolysis: the Royal College of General Practitioners' myocardial infarction study

OBJECTIVE

To investigate whether there is a long-term survival benefit from receipt of thrombolysis in routine care particularly pre-hospital thrombolysis, using 20 year mortality data from the RCGP myocardial infarction (MI) cohort study.

METHODS

During 1991-92 the RCGP MI study assessed GP delivery of thrombolysis. Participants who received pre-hospital thrombolysis (n = 290), thrombolysis in hospital (n = 781) or no thrombolysis (n = 2021) were followed and mortality data collected to June 2012. The relationship between thrombolysis and survival time was analysed using Cox regression at 28 days, 1, 5, 10, 15 years post-AMI, and at end of follow-up (~20 years post-AMI).

RESULTS

Compared to those who did not receive it, participants who received thrombolysis had a significant survival benefit at 28 days [adjusted hazard ratio (HR) 0.72, 95% confidence interval (CI): 0.58-0.90]; 1 year (adjusted HR 0.69, 95% CI: 0.57-0.83); 5 years (adjusted HR 0.76, 95% CI: 0.66-0.86); 10 years (adjusted HR 0.85, 95% CI: 0.77-0.95) and 15 years (adjusted HR 0.88, 95% CI: 0.80-0.96) post-AMI until end of follow-up (adjusted HR 0.92, 95% CI: 0.84-1.00). Pre versus in-hospital thrombolysis did not appear beneficial, although there was evidence among the pre-hospital group that short symptom onset-to-needle times conferred greater benefit.

CONCLUSIONS

We found substantial long-term survival benefits associated with thrombolysis when used in routine care. Although primary percutaneous coronary intervention (pPCI) is now the choice treatment, thrombolysis remains an important option when pPCI cannot be delivered within 120 minutes of diagnosis.

The incidence and risk factors of associated acute myocardial infarction (AMI) in acute cerebral ischemic (ACI) events in the United States

Objectives

To determine the association between myocardial infarction (AMI) and clinical outcome in patients with primary admissions diagnosis of acute cerebral ischemia (ACI) in the US.

Methods

Data from Nationwide Inpatient Sample (NIS) was queried from 2002–2011 for inpatient admissions of patients with a primary diagnosis of ACI with and without AMI using International Classification of Diseases, Ninth Revision, Clinical Modification coding (ICD-9). A multivariate stepwise regression analysis was performed to assess the correlation between identifiable risk factors and clinical outcomes.

Results

During 10 years the NIS recorded 886,094 ACI admissions with 17,526 diagnoses of AMI (1.98%). The overall cumulative mortality of cohort was 5.65%. In-hospital mortality was associated with AMI (aOR 3.68; 95% CI 3.49–3.88, p≤0.0001), rTPA administration (aOR 2.39 CI, 2.11–2.71, p<0.0001), older age (aOR 1.03, 95% CI, 1.03–1.03, P<0.0001) and women (aOR 1.06, 95% CI 1.03–1.08, P<0.0001). Overall, mortality risk declined over the course of study; from 20.46% in 2002 to 11.8% in 2011 (OR 0.96, 95% CI 0.95–0.96, P<0.0001). Survival analysis demonstrated divergence between the AMI and non-AMI sub-groups over the course of study (log-rank p<0.0001).

Conclusion

Our study demonstrates that although the prevalence of AMI in patients hospitalized with primary diagnosis of ACI is low, it negatively impacts survival. Considering the high clinical burden of AMI on mortality of ACI patients, a high quality monitoring in the event of cardiac events should be maintained in this patient cohort. Whether prompt diagnosis and treatment of associated cardiovascular diseases may improve outcome, deserves further study.

Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention?

In the past ten years, primary percutaneous coronary intervention (PCI) has replaced thrombolysis as the revascularisation strategy for many patients presenting with ST-segment elevation myocardial infarction (STEMI). However, delivery of primary PCI within evidence-based timeframes is challenging, and health-care provision varies substantially worldwide. Consequently, even with the ideal circumstances of rapid initial diagnosis, long transfer delays to the catheter laboratory can occur. These delays are detrimental to outcomes for patients and can be exaggerated by variations in timing of patients' presentation and diagnosis. In this Series paper we summarise the value of immediate out-of-hospital thrombolysis for STEMI, and reconsider the potential therapeutic interface with a contemporary service for primary PCI. We review recent trial data, and explore opportunities for optimisation of STEMI outcomes with a pharmacoinvasive approach.

Infarct artery distribution and clinical outcomes in occluded artery trial subjects presenting with non-ST-segment elevation myocardial infarction (from the long-term follow-up of Occluded Artery Trial [OAT])

We hypothesized that the insensitivity of the electrocardiogram in identifying acute circumflex occlusion would result in differences in the distribution of the infarct-related artery (IRA) between patients with non-ST-segment elevation myocardial infarction (NSTEMI) and STEMI enrolled in the Occluded Artery Trial. We also sought to evaluate the effect of percutaneous coronary intervention to the IRA on the clinical outcomes for patients with NSTEMI. Overall, those with NSTEMI constituted 13% (n = 283) of the trial population. The circumflex IRA was overrepresented in the NSTEMI group compared to the STEMI group (42.5 vs 11.2%; p <0.0001). The 7-year clinical outcomes for the patients with NSTEMI randomized to percutaneous coronary intervention and optimal medical therapy versus optimal medical therapy alone were similar for the primary composite of death, myocardial infarction, and class IV congestive heart failure (22.3% vs 20.2%, hazard ratio 1.20, 99% confidence interval 0.60 to 2.40; p = 0.51) and the individual end points of death (13.8% vs 17.0%, hazard ratio 0.82, 99% confidence interval 0.37 to 1.84; p = 0.53), myocardial infarction (6.1 vs 5.1%, hazard ratio 1.11, 99% confidence interval 0.28 to 4.41; p = 0.84), and class IV congestive heart failure (6.7% vs 6.0%, hazard ratio 1.50, 99% confidence interval 0.37 to 6.02; p = 0.45). No interaction was seen between the electrocardiographically determined myocardial infarction type and treatment effect (p = NS). In conclusion, the occluded circumflex IRA is overrepresented in the NSTEMI population. Consistent with the overall trial results, stable patients with NSTEMI and a totally occluded IRA did not benefit from randomization to percutaneous coronary intervention.

Gender differences in anticoagulation and antithrombotic therapy

Cardiovascular disease is the main cause of mortality and morbidity worldwide. The rate of thromboembolic events has increased in women but not in men. Large clinical studies support the use of a variety of antithrombotic drugs for the treatment of patients with different cardiovascular diseases. The heterogeneous patient population included in these trials affects the attempt to generalize the study results to subgroups, which are not sufficiently represented in the study population, such as women and other minorities. Gender-related differences in the clinical presentation and outcome seem to relate to differences in platelet biology and coagulation reactions, resulting in different rates of thromboembolic and bleeding events. The effectiveness of antithrombotic therapies and the occurrence of adverse events define the clinical benefit of the treatment for each patient. This chapter gives an overview of the currently available data on gender-differences in anticoagulation and antithrombotic therapy.

The chronic kidney disease model: a general purpose model of disease progression and treatment

BACKGROUND

Chronic kidney disease (CKD) is the focus of recent national policy efforts; however, decision makers must account for multiple therapeutic options, comorbidities and complications. The objective of the Chronic Kidney Disease model is to provide guidance to decision makers. We describe this model and give an example of how it can inform clinical and policy decisions.

METHODS

Monte Carlo simulation of CKD natural history and treatment. Health states include myocardial infarction, stroke with and without disability, congestive heart failure, CKD stages 1-5, bone disease, dialysis, transplant and death. Each cycle is 1 month. Projections account for race, age, gender, diabetes, proteinuria, hypertension, cardiac disease, and CKD stage. Treatment strategies include hypertension control, diabetes control, use of HMG-CoA reductase inhibitors, use of angiotensin converting enzyme inhibitors, nephrology specialty care, CKD screening, and a combination of these. The model architecture is flexible permitting updates as new data become available. The primary outcome is quality adjusted life years (QALYs). Secondary outcomes include health state events and CKD progression rate.

RESULTS

The model was validated for GFR change/year -3.0 ± 1.9 vs. -1.7 ± 3.4 (in the AASK trial), and annual myocardial infarction and mortality rates 3.6 ± 0.9% and 1.6 ± 0.5% vs. 4.4% and 1.6% in the Go study. To illustrate the model's utility we estimated lifetime impact of a hypothetical treatment for primary prevention of vascular disease. As vascular risk declined, QALY improved but risk of dialysis increased. At baseline, 20% and 60% reduction: QALYs = 17.6, 18.2, and 19.0 and dialysis = 7.7%, 8.1%, and 10.4%, respectively.

CONCLUSIONS

The CKD Model is a valid, general purpose model intended as a resource to inform clinical and policy decisions improving CKD care. Its value as a tool is illustrated in our example which projects a relationship between decreasing cardiac disease and increasing ESRD.

Journey in antithrombotic strategies for ST-elevation myocardial infarction

Our understanding and treatment of the ST-elevation myocardial infarction (STEMI) has led to a tremendous improvement in the care and preservation of life affecting millions yearly. As the medical community continues to discover novel strategies in therapeutics and innovations in prevention, it is imperative to understand the scientific journey the treatment of STEMI has traveled. Furthermore, the research pillars that led to our understanding of the current paradigm of STEMI will be highlighted in an effort to illuminate the foundation on which we now stand.

Comparison of long-term mortality after percutaneous coronary intervention in patients treated for acute ST-elevation myocardial infarction versus those with unstable and stable angina pectoris

Data remain limited regarding the comparative long-term mortality across the spectrum of patients with different indications for percutaneous coronary intervention (PCI). We evaluated early and late mortality in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary PCI compared with early and late mortality in patients undergoing PCI for unstable angina (UA) or non-STEMI (NSTEMI) and stable angina. A total of 10,549 consecutive patients undergoing PCI from 1997 to 2005 at a single institution were followed up prospectively (median 3.2 years, interquartile range 1.5 to 5.6) to assess all-cause mortality. The indication for PCI was STEMI in 28%, UA/NSTEMI in 32%, and stable angina in 40%. The mortality rate at 6 years was 18.9% in patients with STEMI, 16.2% in patients with UA/NSTEMI, and 11.7% in those with stable angina. During the initial 6 months, patients with STEMI had an increased risk of death compared with patients with UA/NSTEMI (relative risk [RR] 3.09, 95% confidence interval [CI] 2.46 to 3.89) and stable angina (RR 5.82, 95% CI 4.45 to 7.62). However, between 6 months and 6 years, mortality accrued at an almost similar rate among patients with STEMI and those with stable angina (RR 1.06, 95% CI 0.86 to 1.32) and mortality was greatest in patients with UA/NSTEMI (UA/NSTEMI vs stable angina: RR 1.33, 95% CI 1.11 to 1.58; STEMI vs UA/NSTEMI: RR 0.80, 95% CI 0.65 to 0.99). In conclusion, we have demonstrated that the inferior survival rates in patients with STEMI after primary PCI are mainly attributed to greater mortality in the first months after the event. These observations highlight that new adjunctive therapeutic strategies should aim at mortality reduction in the first months after primary PCI.

Target populations and relevant therapeutic end points to further improve outcomes in NSTEACS patients

An aggressive pharmaco-interventional approach has been shown to improve long-term outcome among high-risk patients with acute coronary syndromes without ST-segment elevation (NSTEACS). However, these patients continue to represent a minority among those enrolled in clinical trials, thus precluding the possibility to further improve therapeutic efficacy. Target populations that are not adequately addressed by the majority of therapeutic trials are mainly the elderly and those with reduced renal function, who all show unfavorable outcome after an episode of NSTEACS. In order to allow comparison among different studies, a prerequisite for the planning of meaningful trials should be a uniform definition of the study end points besides mortality, particularly with reference to recurrent myocardial infarction, and rehospitalization owing to cardiovascular instability or severe bleeding. In addition to trial design issues, improvements in the regulatory rules for drug development and in hospital networking conceal significant opportunities to improve treatment of NSTEACS.

National Cholesterol Education Panel III performance in preventing myocardial infarction in young adults

BACKGROUND

Only one published trial has directly evaluated the utility of the new National Cholesterol Education Program (NCEP) guidelines in young adults and that study population consisted of young Americans. We examined the utility of the latest NCEP Adult Treatment Panel III (ATP III) guidelines in a group of young Lebanese adults.

METHODS

A group of 234 young adults admitted for myocardial infarction at a Lebanese teaching hospital over a 2-year period were evaluated retrospectively. The Framingham risk predictor model was used to calculate the 10-year risk for coronary events in all subjects.

RESULTS

Two hundred young Lebanese adults with a mean age of 49.7+/-7.6 years were included in the analysis. The majority of the study population had a history of smoking (67%) and LDL cholesterol <130 mg/dL (70.5%) and were considered overweight and obese (80.5%). As a group, 80% did not meet the criteria to qualify for antilipemic pharmacotherapy prior to their presentation.

CONCLUSION

The predictive model did not detect the majority of these patients. Clinicians should treat modifiable risk factors with the same intensity given to cholesterol even if the patient has a normal lipid profile.

Lack of benefit with percutaneous intervention for late persistent occlusion after myocardial infarction: summary of the occluded artery trial

The clinical utility of establishing late patency of the persistently occluded infarct-related artery with percutaneous coronary intervention (PCI) was uncertain. The Occluded Artery Trial was a National Heart, Lung, and Blood Institute-supported, international, multicenter, randomized controlled trial comparing a test strategy of late PCI (3-28 days) of the occluded infarct-related artery and optimal medical therapy to optimal medical therapy alone. The primary end point of the trial was a centrally adjudicated composite of death, reinfarction, and New York Heart Association class IV heart failure over 4 years (mean follow-up, 1,059 +/- 11 days). The final study population of 2,166 patients gave the trial 94% power to detect the anticipated 25% reduction in event rate with PCI. The combined primary outcome occurred in 161 patients in the PCI group and in 140 subjects receiving medical therapy alone. The 4-year cumulative primary event rate was 17.2% in the PCI group and 15.6% in the medical therapy group (hazard ratio, 1.16; 95% confidence interval, 0.92-1.45; P = .20; covariate-adjusted hazard ratio, 1.17; 95% confidence interval, 0.93 to 1.47; P = .18). Rates of New York Heart Association class IV heart failure and death were similar in both groups. A trend toward increased nonfatal myocardial infarction in the PCI group (hazard ratio, 1.44; 95% confidence interval, 0.96-2.16; P = .08) unrelated to periprocedural events was apparent. No significant interaction between treatment effect and prespecified subgroups was observed. This lack of clinical benefit supports optimal medical therapy alone for Occluded Artery Trial-eligible patients in current clinical practice.

Early management of ST elevation myocardial infarction: a review of practice

The last two decades of the 20th century witnessed continuous evolution in the understanding of the pathophysiology of ST elevation myocardial infarction. In parallel, the management of these patients developed steadily throughout this time and into the early years of the 21st century. From humble beginnings involving oxygen therapy, bed rest and analgesia, the relative merits of different strategies to open 'infarct-related arteries' (IRAs) are now being debated: pharmacological reperfusion, mechanical reperfusion or a combination of both these modalities. The current understanding of the process of thrombotic occlusion of the coronary artery has led to the appreciation of the importance of not simply opening the IRA, but also maintaining its patency once opened. Considerable attention is now being afforded to the significant minority of patients who do not achieve early, complete myocardial reperfusion, despite restoration of adequate flow down the epicardial IRA. Those patients who fail to achieve myocardial reperfusion, either due to late presentation or failure of reperfusion therapy, and are left with permanent myocardial scarring can now be considered. This article critically appraises the recent and emerging evidence and clinical implications of the contemporary management of ST elevation myocardial infarction.

Management of Perioperative Myocardial Infarction in Noncardiac Surgical Patients

Perioperative myocardial infarction (PMI) is a major cause of morbidity and mortality in patients undergoing noncardiac surgery. The incidence of PMI varies depending on the method used for diagnosis and is likely to increase as the population ages. Studies have examined different methods for prevention of myocardial infarction (MI), including the use of perioperative beta-blockers, alpha(2)-agonists, and statin therapy. However, few studies have focused on the treatment of PMI. Current therapy for acute MI generally involves anticoagulation and antiplatelet therapy, raising the potential for surgical site hemorrhage in this population. This article reviews the possible mechanisms, diagnosis, and treatment options for MI in the surgical setting. We also suggest algorithms for treatment.

Impaired platelet adhesion to lysed fibrin, whereas neutrophil adhesion remains intact under conditions of flow

Vessel wall injury induces the formation of a haemostatic plug. Restoration of vascular integrity should involve cessation of further platelet and fibrin deposition and subsequent removal of these thrombi by both the fibrinolytic system and proteases delivered by infiltrating inflammatory cells. We hypothesized that adhesion of platelets and inflammatory cells [polymorphonuclear leucocyte (PMN)] to fibrin is differently supported after exposure of fibrin during fibrinolysis. Fibrin surfaces were exposed to fibrinolytic agents, and platelet and PMN adhesion was studied under conditions of flow. Specific adhesion of platelets to preformed fibrin was reduced by fibrinolytic treatment of the fibrin. PMN adhesion to fibrin was only slightly affected even after 180 min exposure to plasmin. With fibrin still present after fibrinolytic treatment, the impaired platelet adhesion seems explained by loss of the primary platelet adhesion site gamma400-411 on fibrin. PMN binding to fibrin clearly depends on other sites that are less degraded by fibrinolysis. We have shown that PMN adhesion in flowing blood to lysed fibrin was still present, whereas platelet adhesion was impaired due to the loss of the primary platelet adhesion site gamma400-411. Based on our in-vitro perfusion model, we conclude that fibrinolysis specifically interferes with the thrombogenicity of fibrin in the haemostatic plug, whereas the inflammatory response is preserved. The latter may participate in the long-term removal and restructuration of the plug.

Early management of ST-segment elevation myocardial infarction

Improvements in the management of ST-segment elevation myocardial infarction(STEMI) have led to a reduction in the acute and long-term mortality rates. The first important decision in the care of patients who have STEMI is the method of reperfusion. Whether percutaneous intervention (PCI) or fibrinolytic therapy is chosen depends on a number of factors. This article reviews the data on PCI and fibrinolytics in the context of consensus guidelines, outlines adjunctive medical therapies important in the first 24 hours, and discusses a strategy for making the decisions and a hypothetical construct for evaluating new drugs and procedures in the future.

Design and methodology of the Occluded Artery Trial (OAT)

Experimental and clinical studies have suggested that late opening of an infarct-related artery (IRA) after myocardial infarction (MI) could improve clinical outcome. However, the suggestive observational data are limited by selection biases. Indeed, most small randomized studies have not demonstrated benefit. Thus, there is no recommendation for routine late opening of the IRA in current national guidelines for management of stable post-MI patients. The OAT is designed to test the hypothesis that opening a totally occluded IRA 3 to 28 days after MI in high-risk asymptomatic patients will improve clinical outcome and be cost-effective. The primary end point is the first occurrence of recurrent MI, hospitalization/treatment of New York Heart Association class IV congestive heart failure, or death. Trial background, design, and preliminary baseline characteristics of 2027 randomized patients are presented. Eligible patients are randomly assigned in equal proportions to optimal evidence-based medical care or optimal care plus late opening of the IRA using percutaneous coronary intervention of the occluded IRA. Treatment groups will be compared using intent-to-treat analysis. The results of OAT should have broad clinical impact by defining an evidence-based approach to the asymptomatic, high-risk, post-MI patient with an occluded IRA. If the efficacy and cost-effectiveness of percutaneous coronary intervention are established, then a policy of routinely seeking and opening persistently occluded IRAs could be advocated. If not, this strategy should be avoided in this large subgroup of post-MI patients.

Sustained Benefit 20 Years After Reperfusion Therapy in Acute Myocardial Infarction

OBJECTIVES

The goal of this research was to clarify whether the benefit of reperfusion therapy for myocardial infarction was sustained long-term and to assess the gain in life expectancy by reperfusion therapy.

BACKGROUND

Reperfusion therapy in acute myocardial infarction reduces infarct size and increases hospital survival.

METHODS

We analyzed the 20-year outcome of 533 patients (mean age 56 years; 82% men) who were randomized to either reperfusion therapy or conventional therapy during the years 1981 to 1985.

RESULTS

Mean follow-up was 21 years (range 19 to 23 years). At follow-up, 101 patients (36%) of the 269 patients allocated to reperfusion treatment and only 71 patients (26%) of the 264 conventionally treated patients were alive (p = 0.02). The cumulative 10-, 15-, and 20-year survival rates were 69%, 48%, and 37% after reperfusion therapy and 59%, 38%, and 27% in the control group, respectively (p = 0.005). Life expectancy of the reperfusion group was 15.2 years versus 12.4 years in the conventionally treated group (p < 0.0001). Myocardial re-infarction and subsequent coronary interventions were more frequent after reperfusion therapy, particularly during the first year. In multivariable analysis, reperfusion therapy was an important independent predictor of lower mortality at long-term follow-up (hazard ratio 0.7; 95% confidence interval 0.6 to 0.8). Other independent predictors of mortality were age, impaired left ventricular function, multivessel disease, infarct size, and inability to perform an exercise test at the time of discharge.

CONCLUSIONS

This is the first study demonstrating sustained (20-year) improved survival after reperfusion therapy. The gain in life expectancy was almost three years, representing about one-third of the life-years lost by myocardial infarction.

Personality traits and heart rate variability predict long-term cardiac mortality after myocardial infarction

AIMS

To investigate personality traits and sympatho-vagal modulation of heart rate variability (HRV) during acute myocardial infarction (AMI), assessing their relationships and their long-term prognostic value.

METHODS AND RESULTS

Psychological traits and 24 h HRV were prospectively investigated in 246 patients at discharge of an AMI. Patients were followed-up to 8 years for the occurrence of cardiac death and non-fatal reinfarction. Low coping and anxiety traits associated with reduced HRV characterized the study population. At univariate analysis, low emotional sensitivity and insecurity, relative tachycardia, reduced high frequency (HF), and low frequency power and pNN50 were predictive of cardiac death at 8-year follow-up. At multivariable analysis, low emotional sensitivity and low HF power remained predictive, with a relative risk of 4.18 (P=0.003) and 2.76 (P=0.007), respectively; also the type of infarction (Q vs. non-Q) and hospital length of stay were independent predictive variables.

CONCLUSION

Anxiety and emotional sensitivity were significant predictors of 8-year cardiac mortality after AMI. Reduced HF power, a recognized marker of vagal withdrawal, increased the risk.

Management of acute coronary syndromes, a questionnaire survey of the clinical practice of cardiologists and other medical physicians belonging to west midland hospitals

OBJECTIVE

To assess the management of acute coronary syndromes by cardiologists and other medical physicians in a clinical setting.

DESIGN

Questionnaire survey consisting of 10 hypothetical clinical scenarios and four possible therapeutic options for each scenario.

SETTING

Consultants and specialist registrars in Cardiology (with or without access to interventional facilities) and consultant physicians belonging to various hospitals in the west midland region of United Kingdom.

MAIN OUTCOME MEASURES

Respondents' ability to recognise high risk patients and their management of the hypothetical clinical cases. To establish any differences in management strategy between cardiologists and general physicians, and whether these differences, if any, relate to access to interventional cardiac facilities.

RESULTS

Overall no significant differences were found in the responses between cardiologists and general physicians with or without access to cardiac interventional facilities. However, cardiologists were more inclined to use percutaneous transluminal coronary angioplasty (PTCA) compared to other physicians (scenario 8, 18.4% vs. 6.7%, p = 0.05 and scenario 9, 44.9% vs. 26.7%, p = 0.01). In two other situations, physicians from institutions with access to interventional facilities were more inclined to use 'other' treatment strategies (intravenous nitrates, antiplatelet treatment, inotropes, Intra-aortic balloon pump) compared to their colleagues from non-tertiary hospitals with no interventional facility on site (scenario 3, 21.7% vs. 2.4%, p = 0.04) and more use of PTCA ( scenario 6, 52.2% vs. 26.8%, p = 0.04).

CONCLUSIONS

The management of acute coronary syndromes in this questionnaire survey was satisfactory and evidence based. No real differences were found between the management strategies adopted by cardiologists or non-cardiologists. Physicians working in centres with interventional facilities were no more inclined towards using primary PTCA or rescue angioplasty than those working in centres without such facilities.

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.

Thrombolysis and Adjunctive Therapy in Acute Myocardial Infarction

This chapter about antithrombotic therapy for acute myocardial infarction (MI) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with ischemic symptoms characteristic of acute MI of < 12 h in duration, and ST-segment elevation or left bundle-branch block (of unknown duration) on the ECG, we recommend administration of any approved fibrinolytic agent (Grade 1A). We recommend the use of streptokinase, anistreplase, alteplase, reteplase, or tenecteplase over placebo (all Grade 1A). For patients with symptom duration < 6 h, we recommend the administration of alteplase over streptokinase (Grade 1A). For patients with known allergy or sensitivity to streptokinase, we recommend alteplase, reteplase, or tenecteplase (Grade 1A). For patients with acute posterior MI of < 12 h duration, we suggest fibrinolytic therapy (Grade 2C). In patients with any history of intracranial hemorrhage, closed head trauma, or ischemic stroke within past 3 months, we recommend against administration of fibrinolytic therapy (Grade 1C+). For patients with acute ST-segment elevation MI whether or not they receive fibrinolytic therapy, we recommend aspirin, 160 to 325 mg p.o., at initial evaluation by health-care personnel followed by indefinite therapy, 75 to 162 mg/d p.o. (both Grade 1A). In patients allergic to aspirin, we suggest use of clopidogrel as an alternative therapy to aspirin (Grade 2C). For patients receiving streptokinase, we suggest administration of either i.v. unfractionated heparin (UFH) [Grade 2C] or subcutaneous UFH (Grade 2A). For all patients at high risk of systemic or venous thromboembolism (anterior MI, pump failure, previous embolus, atrial fibrillation, or left ventricular thrombus), we recommend administration of IV UFH while receiving streptokinase (Grade 1C+).

When to Stress Over Triptans: A Markov Analysis of Cardiovascular Risk in Migraine Treatment

BACKGROUND

Migraines affect 10% of the U.S. population and the episodes are frequently associated with significant disability. Triptans, 5HT1 receptor agonists, can be highly effective in treating pain and reducing disability. However, reports of cardiac events associated with triptan ingestion have led to concerns about its use in the face of possible cardiac disease.

OBJECTIVE

Should a patient without known cardiovascular disease (CAD) and moderately severe to severe migraines undergo cardiovascular testing prior to the initiation of triptan therapy?

DESIGN

A Markov model of migraine and cardiac disease using DATA 4.0. Three strategies were compared: (1) use triptans without further evaluation (TREAT); (2) test, then treat if negative (TEST); and (3) avoid triptans (NOTRIPTAN). Triptans were prohibited if a cardiac event occurred.

DATA

Model inputs were derived from the literature and subjected to sensitivity analyses across all possible values.

TIME HORIZON

Markov cycle is 1 week.

OUTCOMES

The primary outcomes of interest were quality-adjusted life expectancy, in years (QALYs) and the impact of various cardiovascular risk levels on the preferred strategy.

RESULTS

For the base case results were TREAT 19.4 QALYs, TEST 19.2, NOTRIPTAN 19.1. When altering CAD probability: TREAT dominated from 0 to 87%, TEST 87% to 97%, and NOTRIPTAN above 97%. Results were robust during sensitivity analyses.

CONCLUSIONS

This analysis suggests that even for individuals with a relatively high risk of CAD it is not beneficial to perform cardiac testing, nor to avoid triptans. The exact level of cardiac risk at which testing should be considered is probably at or above 87%.

Effect of clopidogrel on tissue-plasminogen activator-induced in vitro thrombolysis of feline whole blood thrombi

OBJECTIVE

To determine if clopidogrel enhanced the thrombolytic rate of tissue-plasminogen activator (t-PA) on an in vitro feline whole blood thrombosis model.

ANIMALS

9 purpose-bred cats.

PROCEDURE

Blood obtained from cats before (baseline) and after treatment with clopidogrel (75 mg, p.o., q 24 h for 3 days) was anticoagulated with sodium citrate (9:1 volume-to-volume ratio) to which 1 microCi of I125-fibrinogen was added. Thrombi were formed by the addition of calcium chloride and bovine thrombin. Thrombi were placed into autologous plasma to which 0.1 mg of t-PA was added. Plasma samples were collected at different time points to determine the amount of released I125-fibrin split products. Thrombolytic rates were calculated by determining the time to 25%, 50%, and 75% thrombolysis (t25, t50, and t75, respectively). Confidence intervals for t25, t50, and t75 at baseline were compared with those after treatment.

RESULTS

There were no significant differences in thrombolytic rates between values obtained at baseline and after clopidogrel treatment (t25, 18.0 vs 18.5 minutes; t50, 63.3 vs 65.6 minutes; and t75, 163.0 vs 170.1 minutes, respectively).

CONCLUSIONS AND CLINICAL RELEVANCE

Clopidogrel did not have an effect on the rate of thrombolysis of feline whole blood thrombi induced by t-PA in this in vitro model.

Prevention of coronary heart disease with aspirin and clopidogrel: efficacy, safety, costs and cost-effectiveness

Atherothrombotic coronary artery disease is the single most common cause of death worldwide and a growing public health problem. Platelets play a central role in the pathogenesis of atherothrombosis and are therefore commonly targeted by one or more antiplatelet drugs as part of primary and secondary atherothrombosis prevention strategies. Aspirin reduces the risk of serious vascular events (myocardial infarction, stroke or cardiovascular death) by approximately 20% in a broad range of high-risk patients and remains the first-line antiplatelet drug because of its relative safety, low cost and cost-effectiveness. Compared with aspirin alone, clopidogrel reduces the risk of serious vascular events by approximately 10% and the combination of aspirin and clopidogrel reduces the risk by approximately 20% in patients with non-ST-segment elevation acute coronary syndrome. Clopidogrel has a similar safety profile to aspirin but clopidogrel tablets are substantially more expensive. However, the incremental cost-effectiveness ratio of clopidogrel compared with aspirin is favourable, particularly in high-risk patients and is intermediate compared with a range of other effective therapeutic strategies for the treatment of coronary heart disease. Clopidogrel should be considered as a replacement for aspirin in patients who are allergic to aspirin, cannot tolerate aspirin, have experienced a recurrent atherothrombotic vascular event whilst taking aspirin and are at very high absolute risk of a serious vascular event (e.g., > 20%/year). The combination of clopidogrel and aspirin should be considered in patients with non-ST-segment elevation acute coronary syndrome or undergoing percutaneous coronary intervention.