STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial

BACKGROUND

ST-segment-elevation myocardial infarction (STEMI) guidelines recommend pharmaco-invasive treatment if timely primary percutaneous coronary intervention (PCI) is unavailable. Full-dose tenecteplase is associated with an increased risk of intracranial hemorrhage in older patients. Whether pharmaco-invasive treatment with half-dose tenecteplase is effective and safe in older patients with STEMI is unknown.

METHODS

STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) was an investigator-initiated, open-label, randomized, multicenter study. Patients ≥60 years of age with ≥2 mm ST-segment elevation in 2 contiguous leads, unable to undergo primary PCI within 1 hour, were randomly assigned (2:1) to half-dose tenecteplase followed by coronary angiography and PCI (if indicated) 6 to 24 hours after randomization, or to primary PCI. Efficacy end points of primary interest were ST resolution and the 30-day composite of death, shock, heart failure, or reinfarction. Safety assessments included stroke and nonintracranial bleeding.

RESULTS

Patients were assigned to pharmaco-invasive treatment (n=401) or primary PCI (n=203). Median times from randomization to tenecteplase or sheath insertion were 10 and 81 minutes, respectively. After last angiography, 85.2% of patients undergoing pharmaco-invasive treatment and 78.4% of patients undergoing primary PCI had ≥50% resolution of ST-segment elevation; their residual median sums of ST deviations were 4.5 versus 5.5 mm, respectively. Thrombolysis In Myocardial Infarction flow grade 3 at last angiography was ≈87% in both groups. The composite clinical end point occurred in 12.8% (51/400) of patients undergoing pharmaco-invasive treatment and 13.3% (27/203) of patients undergoing primary PCI (relative risk, 0.96 [95% CI, 0.62-1.48]). Six intracranial hemorrhages occurred in the pharmaco-invasive arm (1.5%): 3 were protocol violations (excess anticoagulation in 2 and uncontrolled hypertension in 1). No intracranial bleeding occurred in the primary PCI arm. The incidence of major nonintracranial bleeding was low in both groups (<1.5%).

CONCLUSIONS

Halving the dose of tenecteplase in a pharmaco-invasive strategy in this early-presenting, older STEMI population was associated with electrocardiographic changes that were at least comparable to those after primary PCI. Similar clinical efficacy and angiographic end points occurred in both treatment groups. The risk of intracranial hemorrhage was higher with half-dose tenecteplase than with primary PCI. If timely PCI is unavailable, this pharmaco-invasive strategy is a reasonable alternative, provided that contraindications to fibrinolysis are observed and excess anticoagulation is avoided.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02777580.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

IgM and IgG antibodies against SARS-CoV-2 in neonates born to mothers with COVID-19

Immunity against the novel coronavirus infection in neonates born to mothers with PCR-confirmed COVID-19 is an understudied field of research. The aim of this study was to analyze the levels of IgM and IgG antibodies against SARS-CoV-2. The study was carried out in 20 mothers aged 19 to 39 years and 21 neonates (including a pair of twins). Babies born to mothers with elevated IgM and IgG against SARS-CoV-2 also had elevated IgG. There is a hypothesis that anti-SARS-CoV-2 IgM are not passed on to the child across the placenta. In all cases studied in this work, neonates were PCR-negative for the virus, which suggests the absence of vertical COVID-19 transmission. Further research is needed.

P1339 Clinical masks of aortic aneurysm: staged rupture of an aortic aneurysm under the guise of a recurrent infection

A 63-year-old man was admitted to the medical intensive care unit because of hypotension and suspected sepsis. Two months before he was admitted to military hospital for cerebrovascular event, considered as transient ischemic attack. Few days after discharge the fever (with a temperature of 39.5°C) occurred and patient was readmitted to the same hospital. Empirical treatment with cefalosporine was inefficient. Only combination carbapenem and vancomycin after E.coli was verified in blood culture stopped the infection. With normal body temperature, normal leukocytes count, mild azotemia, sterile blood and urine cultures and diagnosis of treated urosepsis patient was discharged. Two echocardiogram during hospital stay found no abnormal findings and chest CT scan was also normal.

Seven days later, he was seen in our hospital because of fever (with a temperature of 40°C), severe sweating and arterial hypotension. Immediately fluids and norepinephrine infusion was started. Fluoroquinolone was chosen as an antibiotic.

There was complete LBBB on ECG that had been registered previously. Leucocyte count at admission was 14 x 109/l and creatinine 300 µmol/l. Transthoracic echo (TTE) reportedly showed evidence of mild aortic and mitral regurgitations, pericardial effusion (1.0 – 1.3 cm with signs of right atrium compression). Aortic root seemed quite normal. On the third day, the number of leukocytes and creatinine increased significantly, reaching 450 µmol/l and 41 x 109/l respectively. Chest CT scan revealed signs of bilateral pneumonia, pericardial and left-sided pleural effusions. Vancomycin and ceftriaxone intravenously were started. Transesophageal echo revealed degenerative changes of aortic valve with mild insufficiency, mild mitral regurgitation. The amount of fluid in the pericardium was approximately unchanged. Patient became normotensive and norepinephrine infusion was discontinued. On the 6th day after admission patient’s temperature became normal, level of creatinine decreased to 230 µkmol/l and leukocytes reached 11.4 x 109/l. On the same day, the patient"s condition worsened. He complained of mild heartburn and progressive weakness, the number of leukocytes and the activity of transaminases increased, his blood pressure dropped to 75/40 mm Hg. This has led to the resumption of norepinephrine infusion. Repeated CT scan revealed inhomogeneous contents in the pericardium. Repeated TTE found increase of pericardial effusion with heterogenous content and signs of cardiac tamponade. Patient was transferred to operating room. After pericardiotomy multiple blood clots and active bleeding from pseudoaneurysm of ascending aorta were found. Despite surgical attempts and massive transfusion, patient died. Autopsy revealed the rupture of pseudoaneurysm of ascending aorta and flat hematoma in pericardium.

Abstract P1339 Figure.

[Randomized Comparison of Two Approaches to Initial Warfarin Dosing: Time in Therapeutic Range of International Normalized Ratio During Hospitalization]

AIM

To perform a randomized, open-label comparison of average time in therapeutic range (TTR) of international normalized ratio (INR) using two approaches to initial warfarin dosing during hospitalization: the standard method and the one using individual patient characteristics (clinical algorithm - the studied approach).

MATERIALS AND METHODS

We randomly assigned 60 patients with different indications for vitamin K antagonist therapy to the studied approach (n=31, intervention group) or to the standard method (n=29, control group). А target INR range for all patients was 2.0 to 3.0.

RESULTS

The average TTR and portions of INR values within target range during the whole time of drug dosing turned out to be small. TTR was 22.4% with standard method and 21.4% with clinical algorithm, which was well below desired 60%.

CONCLUSION

The opportunities for achieving target INR in inpatient settings, regardless of warfarin dosing regimen, are limited.

Long-term follow-up of antithrombotic management patterns in patients with acute coronary syndrome in Russia: an observational study (EPICOR-RUS study)

OBJECTIVE

This study sought to describe the short- and long-term (up to 2 years) antithrombotic management patterns in a real-life setting for patients hospitalized for an acute coronary syndrome (ACS) event, and to document clinical outcomes.

RESEARCH DESIGN AND METHODS

EPICOR-RUS was a multicenter (34 centers), prospective, observational, longitudinal cohort study conducted across Russia on antithrombotic management in hospitalized (within 24 hours of symptom onset) ACS patients with 2 year follow-up.

CLINICAL TRIAL REGISTRATION

NCT01373957.

RESULTS

A total of 600 ACS patients (71.1% male, mean age 60 years) were enrolled; 599 were included for analysis. Diagnosis comprised STEMI (n = 375, 62.6%), NSTEMI (n = 147, 24.5%), and unstable angina (UA) (n = 77, 12.9%). Percutaneous coronary intervention (PCI) was conducted in 64.3% of patients with STEMI (with or without thrombolysis), 36.7% with NSTEMI, and 58.4% with UA. There was undertreatment with dual antiplatelet therapy (DAPT) for STEMI, NSTEMI, and UA: 14.7%, 25.9% and 16.9% of patients, respectively, were not receiving DAPT during hospitalization, and 10.1%, 21.8% and 16.9% at discharge. Post-discharge, of the STEMI group, only 72.4% of patients who were managed by PCI and 39.8% of conservatively treated patients received DAPT at 12 months. The respective figures in the NSTEMI group were 77.3% and 26.4%. In the STEMI cohort the cumulative incidence of all-cause mortality was 3.2% at 1 year and 5.1% at 2 years of follow-up; in the NSTEMI cohort this was 2.7% and 4.8%, respectively. There were no deaths by 12 months and one death by 24 months (1.3%) in the UA population.

CONCLUSION

Despite evidence-based guidelines for the management of ACS, the real-world setting in Russia shows discrepancies in clinical practice, highlighting the need for improvements for the optimal management of high-risk patients with ACS.

[Difficulties in the diagnosis of stroke in pregnant women]

AIM

To study the features of the clinical picture of stroke and results of laboratory/instrumental study in pregnant women.

MATERIAL AND METHODS

A study included 44 women at different periods of gestation (mean age 33.4±9.7 years) with clinical symptoms of stroke hospitalized within 4-11h after stroke. Neuroimaging, clinical/instrumental and laboratory examinations were carried out in the first 40 min after admission.

RESULTS

A routine screening examination during the management of pregnancy in women's consultation clinics does not always reduce the risk of life threatening events. The operative delivery can decrease the severity of the focal neurological deficit. Intensive treatment and dynamic management of patients with intracranial pathology in intensive care stroke unit improves outcome of stroke.

CONCLUSION

A timely differential diagnosis of pathological conditions with different symptoms of stroke at the different stages of medical care of pregnant women helps to choose an optimal treatment plan and improve the outcome.

[Indirect comparison of changes of parameters of hemostasis during short-term use of ticlopidine and clopidogrel in patients with non-ST elevation acute coronary syndrome]

Effects of thienopyridines ticlopidine (TIC) and clopidogrel (CL) on hemostasis in patients (pts) with non-ST-elevation acute coronary syndromes (NSTEACS) have not been compared.

AIM

To compare changes of some markers of coagulation and platelet activation during short term use of TIC and CL in pts with NSTEACS.

METHODS

Aspirin treated pts with NSTEACS (<48 hours from pain onset, Braunwald class IIIb) were included into 2 consecutive studies: 37 pts receiving unfractionated heparin (UFH) were randomized to open TIC (n=19, 500 mg BID for 2 days and 250 mg BID for subsequent 5 days) or no TIC (n=18); 19 pts receiving enoxaparin were randomized to CL (n=10, 300 mg on day 1 and 75 mg/day for subsequent 6 days) or no CL (n=9). At baseline, on days 1, 3, 7 and 14 (7 days after thienopyridines discontinuation) we measured ADP-induced and spontaneous platelet aggregation (PA), levels of prothrombin fragment 1+2 (F1+2), thrombin-antithrombin complex (TAT), von Willebrand factor (vWF), fibrinogen, tissue type plasminogen activator antigen (tPA), plasminogen activator inhibitor activity (PAI) and D-dimer (Dd), and counted platelet number.

RESULTS

Maximal suppression of PA was obtained on 7-th and 3-rd days in TIC and CL groups, respectively. Compared with their controls TIC treated pts in 7 days after TIC discontinuation had lower levels of TAT (3.61 and 2.77 ng/ml, respectively, r<0.05) and fibrinogen (3.84 and 3.16 g/l, respectively, r<0.05). There were no significant differences between intervention and control groups in these parameters in study with CL. Level of vWF in TIC treated pts was lower than in controls on days 3 (163 and 186%, respectively, r<0.05) and 14 (144 and 173%, respectively, p<0.01). In CL treated pts vWF level was lower relative to controls on days 3 and 7 (152 and 185%, r<0.05, 141 and 166%, r<0.05, respectively). tPA levels in study with TIC did not differ between intervention and control groups. tPA in CL treated pts exceeded its level in controls on days 3, 7, and 14 (25.7 and 20.2 ng/ml, 26.5 and 12.9 ng/ml, 24.6 and 15.7 ng/ml, respectively). On the same days level of Dd in pts receiving CL was significantly higher than in control group (969 and 702 ng/ml, 970 and 575 ng/ml, 806 and 484 ng/ml on days 3, 7 and 14, respectively). Activity of PAI in TIC group was higher than in controls on day 7 (13.6 and 8.2 U/l, r<0.05), and at this moment level of Dd was lower in TIC treated patient (770 and 515 ng/ml in control and TIC groups, respectively, r<0.05). CL and control groups had similar PAI activity. Mean platelet volume rose relative to initial level and to control group only in CL treated patients (9.0 and 8.4 fl, 9.6 and 8.4 fl, 9.4 and 8.5 fl in CL and control groups on days 0, 7 and 14, respectively; r<0.05 for comparison between groups on days 7 and 14).

CONCLUSION

In pts with NSTEACS both thienopyridines attenuated acute phase elevation of vWF. The use of TIC in UFH treated pts was associated with indirect signs of decreased thrombin activity and some inhibition of fibrinolysis while the use of CL in enoxaparin treated pts was associated with signs of activation of fibrinolysis.

[Non ST elevation acute coronary syndrome. Parameters of fibrinolysis during short term use of ticlopidine or clopidogrel]

Whether thienopyridines (ticlopidine or clopidogrel) produce similar effects on fibrinolysis in patients with non ST elevation acute coronary syndrome (NSTEACS) was not well elucidated.

AIM

To study changes of parameters of fibrinolysis during short term use of ticlopidine and clopidogrel in NSTEACS patients treated with aspirin and antithrombin.

MATERIAL

Patients with NSTEACS treated with aspirin and unfractionated heparin (UFH, n=37) or enoxaparin (n=19).

METHODS

The UFH treated patients were randomized to ticlopidine (1000 mg/day for 2 and then 500 mg/day for 5 days, n=19) or no ticlopidine (n=18). Enoxaparin treated patients were randomized to either clopidogrel (300 mg/day for 1 and then 75 mg/day for 6 days, n=10) or no clopidogrel (n=9). Levels of tissue plasminogen activator (TPA) antigen, D-dimer, and activity of plasminogen activator inhibitor (PAI) were measured before and in 24 hours, 3, 7, 14 days after randomization.

RESULTS

At baseline values of parameters studied were similar in each pair (thienopiridine - control) of patients groups. Compared with their controls ticlopidine treated patients on day 7 had less pronounced lowering of PAI activity (13.6 and 8.2 U/l, p<0.05) and lower D-dimer concentration (515 and 770 ng/ml, respectively, p<0.05). Clopidogrel treated patients on days 3, 7 and 14 had higher levels of TPA both compared with controls (25.7 and 20.2, p<0.05; 26.5 and 12.9, p<0.01; 24.6 and 15.7 ng/ml, p<0.01; respectively) and baseline. D-dimer levels in these patients on same time points were also higher than in controls (969 and 702, p<0.05, 970 and 575, p<0.01, 806 and 484 ng/ml, p<0.01, respectively).

CONCLUSION

Compared with controls the use of ticlopidine in patients with NSTEACS treated with aspirin and UFH was associated with less pronounced lowering of PAI activity and lower level of D-dimer. This could be interpreted as consequence of inhibition of fibrinolysis. The use of clopidogrel in similar patients treated with aspirin and enoxaparin was associated with elevated levels of TPA and D-dimer what presumably reflected augmentation of fibrinolytic activity.

[Prevention and treatment of venous thromboses and thromboembolism: pentasaccharides as novel anticoagulants selectively blocking Xe factor, their position and potential (data of the XIX International Congress on Thromboses and Hemostasis)]

Drug prevention and treatment of venous thromboses and thromboembolism remain a serious problem in the management of surgical and therapeutic patients. Pentasaccharides, novel anticoagulants selectively blocking Xe factor have a great potential for their use in the given area. It has been demonstrated at the preliminary stages of the study of these antithrombotic agents that their pharmacokinetics permits subcutaneous drug injection once a day (for fondaparinux) and once for 7 days (for indraparinux) without the necessity of making routine coagulologic control. The drugs are marked by bioavailability approximating 100%, linear dose-dependent pharmacokinetic profile at subcutaneous injection; they do not undergo metabolism and are excreted largely with urine. Fondaparinux, the first representative of this class anticoagulants, has evidence for the effectiveness and safety, obtained in large randomized studies carried out in orthopedic and traumatologic patients. The given paper reports the new positive data on evaluation of the preventive action of fondaparinux in therapeutic subjects end patients who had undergone abdominal surgical interventions. Moreover, in large comparative studies , this anticoagulant did yield to the standard agents applied to the treatment of thrombosis of the deep veins and thromboembolism of pulmonary artery branches. Being more handy in use fondaparinux is capable of replacing antithrombotic agents (without efficacy and safety loss) used nowadays for preventive and therapeutic purposes. In the event of successful completion of the evaluation of idraparinux, another pentasaccharide intended for many months of anticoagulant treatment, the goal-oriented use of pentasaccharides is potentially capable of supplanting all the "old" antithrombotic agents from the schedule of the short-term and prolonged prevention and treatment of venous thromboses and thromboembolism.

[Non ST elevation acute coronary syndrome: early use of pravastatin or atorvastatin is associated with divergent changes of parameters of hemostasis]

PURPOSE

To find out whether pravastatin and atorvastatin rapidly (in 1-2 weeks) and similarly affect hemostasis in patients with non-ST elevation acute coronary syndrome (NSTEACS).

METHODS

Ninety aspirin and heparin treated patients with NSTEACS were randomized <24 hours from pain onset to open pravastatin 40 mg/day (n=31), atorvastatin 10 mg/day (n=30) or atorvastatin 40 mg/day (n=29). At baseline, on days 7, 14 plasma thrombin-antithrombin complex (TAT), prothrombin fragments 1+2 (F1+2), D-dimer, von Willebrand factor (vWF) were measured by ELISA. Results were compared with data from controls (n=18) of another randomized study on similarly treated patients.

RESULTS

In all treatment groups levels of low-density lipoprotein cholesterol (LDLCH) were lowered by days 7 (p<0,01) and 14 (p<0,01 vs. baseline and for both atorvastatin groups vs. day 7). In pravastatin group levels of TAT and F1+2 decreased, while vWF level increased. In atorvastatin groups levels of TAT and F 1+2 increased while level of vWF decreased. Contrary to pravastatin group changes in atorvastatin treated patients more resembled those in controls not receiving lipid lowering drugs. Changes of both LDLCH and TCH directly correlated only with changes of vWF (r=0.23, p=0.03 and r=0.25, p=0.02, respectively). No consistent changes of D-dimer occurred.

CONCLUSION

Early use of atorvastatin and pravastatin in patients with NSTEACS was associated with rapid divergent changes of some hemostatic parameters. Except lowering of von Willebrand factor changes in atorvastatin treated patients more resembled those in controls not receiving lipid lowering drugs. Von Willebrand factor was the only parameter which changes weakly but significantly correlated with changes of CH and LDL CH levels.

[Diagnostic value of heart fatty-acid binding protein in early hospitalized patients with non ST elevation acute coronary syndrome]

BACKGROUND

Heart fatty-acid-binding protein (FABP) is supposed to be the most sensitive biomarker of myocardial necrosis in patients with Q-wave myocardial infarction (MI) and non-diagnostic ECG during first hours after onset of symptoms. However, diagnostic value of FABP in patients with non-ST elevation acute coronary syndrome (NSTEACS) is not well established.

AIM

To elucidate diagnostic value of FABP in patients with NSTEACS hospitalized within time interval considered to be too early for a majority of biochemical tests.

MATERIAL AND METHODS

FABP levels were measured by immunofluorometry (HyTest, Finland) in 44 patients (26 men, mean age 69+/-8.9 years) at admission within 6 hours (median - 2 h) from onset of index attack of angina and in 6, 12, 24 hours after onset of pain. Cut off FABP level was 12 ng/ml. Serum cardiac troponin I was measured for diagnosis of MI on admission and twice during first 24 hours of hospital stay. Cut off TnI level was 0.4 ng/ml.

RESULTS

Acute MI was diagnosed by TnI above cut off in 31 patients (70.5%). There were no new-Q-wave MIs. Average ratio of observed serum FABP level to diagnostic cut off value on admission and in 6, 12, 24 hours after onset of pain was higher in patients with MI than in patients with unstable angina (1.01, 1.53, 0.81, 0.66 and 0.78, 0.51, 0.65, 0.56, respectively). The difference was maximally significant in 6 hours after onset of pain (p=0.018). Among patients with MI admission FABP compared with admission TnI more frequently exceeded diagnostic level (in 18 vs 9 patients, respectively, p=0.009). Sensitivity and specificity of admission levels of FABP and TnI for diagnosis of MI were 58 and 85%, 29% and 100%, respectively.

CONCLUSION

In patients with NSTEACS during first 6 hours after pain onset FABP compared with TnI has greater sensitivity for detection of MI and sufficient specificity. FABP can be used as additional diagnostic tool for MI detection in early admitted patients with NSTEACS.

[Markers of inflammation and platelet aggregation in patients with non ST elevation acute coronary syndrome treated with atorvastatin or pravastatin]

AIM

To find out whether early use of atorvastatin and pravastatin in patients with non-ST elevation acute coronary syndrome is associated with rapid changes of platelet aggregation and plasma levels of markers of inflammation.

MATERIAL AND METHODS

Ninety patients (<24h from pain onset, age 64+/-10 years) treated with aspirin and heparin were randomized to open atorvastatin 10 mg/day (n=30), atorvastatin 40 mg/day (n=29) or pravastatin 40 mg/day (n=31). Spontaneous and ADP induced platelet aggregation (light transmission), plasma levels of interleukin 6 (IL-6) and C-reactive protein (CRP) (immunoassay) were assessed at baseline, on days 7 and 14.

RESULTS

Baseline clinical characteristics, platelet aggregation parameters, CRP and IL-6 levels were similar in all groups. In all groups levels of total and low-density lipoprotein (LDL) cholesterol (CH) were lowered by days 7 (p<0.01) and 14 (p<0.01 vs. baseline and for both atorvastatin groups vs. day 7). Spontaneous platelet aggregation decreased by 15% from baseline, p<0.01, on day 14 in patients receiving atorvastatin 40 and was unchanged in other groups. Changes of ADP induced platelet aggregation, IL-6 and CRP levels were not significant in all groups. However combination of 2 atorvastatin groups (n=59) revealed decrease of CRP by 18% from baseline on day 14 (from 6.94+/-0.97 to 4.76+/-0.76 mg/l, p=0.028). No correlations were found between changes of LDL CH and those of other parameters.

CONCLUSION

In otherwise conventionally treated patients with non-ST elevation acute coronary syndrome early use of atorvastatin was associated with rapid (in 14 days) decrease of CRP level. Higher dose of atorvastatin (40 mg/day) induced favorable changes of spontaneous platelet aggregation. There were no significant changes of parameters studied in pravastatin treated patients.

[Feasibility of implementation of guidelines for the management of acute coronary syndrome in cardiac unit of a community hospital]

AIM

To assess feasibility of implementation of Guidelines of Russian Society of Cardiology (RSC) on the management of non ST elevation acute coronary syndrome (adaptation of Guidelines of the European Society of Cardiology) in an ordinary noninvasive community hospital.

METHODS

Retrospective analysis of inhospital management of 266 consecutive patients with acute coronary syndromes without persistent ST elevation admitted to coronary unit of a community hospital in January-July, 2001.

MATERIAL AND RESULTS

Main characteristics of the group: mean age 69 years (34% >75 years), men - 56%, history of myocardial infarction - 38%, hypertension - 67%, diabetes - 23%, pain at rest as an index event - 98%, symptoms duration exceeding 20 min - 61%, ECG changes - 87% (42% ST deviation), signs of left ventricular failure - 14%. Myocardial infarction as index event was diagnosed in 32% of pts by serial measurement of total CK activity. There were no angiographies or revascularizations during hospital stay (20-/+6 days) because of absence of catheterization facilities. Medical treatment: antiplatelet agents - 99% (98% - aspirin) of patients; proportion of patients treated with heparins - 83% (low molecular weight heparins - 18,5%). Most of the patients received b-blockers (79%) and nitrates (78%). Use of calcium channel blockers was relatively low (15%). Few patients (20%) received statins. Inhospital rate of death and nonfatal myocardial infarction was 3,5% i 3%, respectively. Rate of chest pain recurrence was high (38% overall, 26% with ischemic ST-T ECG changes) and at least partially could be explained by the lack of invasive interventions.

CONCLUSION

Management of patients with non ST elevation ACS in coronary unit of a community hospital during the period surveyed in this study was in line with corresponding RSC guidelines (as related to noninvasive treatment) except duration of hospitalization. This was associated with acceptable rate of death or/and myocardial infarction (6,5%) in a group of relatively high risk pts. High rate of angina recurrences during rather long hospital stay reflected absence of invasive treatment.

[Heart fatty acid binding protein in patients with ST-elevation acute coronary syndrome hospitalized within 6 hours after onset of pain]

AIM

To compare diagnostic value of a novel marker of myocardial necrosis heart fatty acid binding protein (FABP) with that of troponin I (TnI) and total creatine kinase (CK) in patients admitted early after onset of ST-elevation acute coronary syndrome.

MATERIAL

Fifty seven patients with ST-segment elevations justifying thrombolytic therapy admitted within 6 hours (29/57 within 3 and 12/57 - 2 hours) after onset of chest pain. In all patients myocardial infarction (MI) was eventually confirmed by development of Q waves and/or diagnostic increase of CK.

METHODS

Samples of blood were taken at admission to coronary care unit. Cut-off values for an elevated level of FABP was 12 ng/ml, TnI - 1.2 and 0.4 ng/ml, CK - 400 IU/l.

RESULTS

Overall FABP was elevated in 47 (83%), TnI - in 16 (28.1%), CK in 7 (12.3%) patients. Among patients admitted within first 3 and 2 hours FABP was elevated in 23/29 (79.3%) and 11/12 (91%), TnI - in 9/29 (31%) and 5/12 (41.7%), CK in 3/29 (10.3%) and 1/12 (8.3%) patients, respectively. The use of lower cut-off of abnormality (0.4 ng/ml) increased proportion of patients with elevated TnI up to 56.1% in the group as a whole, to 48.3% and 50% among patients admitted within first 3 and 2 hours, respectively. Nevertheless proportion of patients with elevated FABP remained higher with difference being significant for the whole group and patients admitted within first 3 hours (p=0.004 and 0.016, respectively).

CONCLUSION

Most patients with ST-elevation acute coronary syndrome hospitalized within 2-6 hours after onset of pain had elevated levels of heart FABP.

[Non-ST elevation acute coronary syndrome: changes of parameters of hemostasis during and after treatment with unfractionated heparin and enoxaparin]

AIM

To compare changes of parameters of hemostasis in patients with non-ST elevation acute coronary syndrome (NSTEACS) during and after treatment with unfractionated heparin (UFH) and low molecular weight heparin (LMWH) enoxaparin.

MATERIAL

Control groups of 2 randomized studies of effects of thienopyridines in NSTEACS with similar inclusion criteria.

METHODS

In patients (n=18) of study one UFH was infused intravenously for 54.2+/-22.3 h, in patients of study two subcutaneous enoxaparin 1 mg/kg b.i.d. was used for 76.2+/-28.3 h. Levels of D-dimer (DD), thrombin-antithrombin complex (TAT), prothrombin fragment 1+2 (F1+2), von Willebrand factor (vWF), fibrinogen, tissue plasminogen activator (TPA) and activity of its inhibitor (PAI), soon after start of treatment with heparins and in 1, 3, 7 and 14 days.

RESULTS AND CONCLUSION

Short term lowering of DD and TAT levels occurred during UFH infusion apparently reflecting primary antithrombin action of UFH. During LMWH use DD level remained unchanged however its lowering was observed after cessation of LMWH (on days 7 and 14). The use of LMWH was not associated with increases of thrombinemia (TAT), thrombin generation (F1+2), and fibrinogen which were registered after end of UFH infusion (days 3, 7 and 14). Neither UFH nor LMWH prevented acute phase vWF elevation. The use of both heparins was associated with changes that could be interpreted as profibrinolytic. In LMWH treated patients these changes (elevations of TPA level) became manifested early (on day 3) and were short lived while in UFH treated patients they appeared later (on day 7) and were prolonged (as lowered PAI activity on day 14).

[Non ST elevation acute coronary syndrome. Some characteristics of coagulation and von Willebrand factor during short term use of ticlopidine or clopidogrel]

Levels of some markers of coagulation and platelet activation such as prothrombin fragment 1+2 (F1+2) thrombin-antithrombin complex (TAT) and von Willebrand factor (vWF), are related to outcome in non ST-segment elevation acute coronary syndrome (NSTEACS). Effects of thienopyridines ticlopidine and clopidogrel on acute changes of these parameters in patients with NSTEACS are not well investigated.

AIM

To study changes of markers of coagulation and platelet activation during short term use of ticlopidine and clopidogrel in NSTEACS patients treated with aspirin and antithrombin.

METHODS

Patients with NSTEACS, treated with aspirin and unfractionated heparin (n=37, <48 hours from pain onset, Braunwald class IIIb) were randomized to open ticlopidine (n=19, 500 mg BID loading dose for 2 days and 250 mg BID for subsequent 5 days) or no ticlopidine (n=18). In another substudy with the same design 19 aspirin and enoxaparin treated patients were randomized to clopidogrel (n=10, 300 mg loading dose and 75 mg/day for subsequent 6 days) or no clopidogrel (n=9). Levels of F1+2, TAT and vWF were measured at baseline, on days 1, 3, 7 and 14 (7 days after discontinuation of thienopyridines).

RESULTS

At baseline values of parameters studied were similar in each pair (thienopyridine - control) of patient groups. Compared with their controls ticlopidine treated patients in 7 days after ticlopidine discontinuation had lower levels of TAT (2.77 and 3.61 ng/ml, r<0.05) and fibrinogen (3.16 and 3.84 g/l, r<0.05). The level of vWF in ticlopidine treated patients was lower relative to control group on days 3 (163 and 186%, r<0.05) and 14 (144 and 173%, p<0.01). In substudy with clopidogrel differences between groups existed only in vWF levels. In clopidogrel treated patients the level vWF was lower relative to controls on days 3 (152 and 185%, r<0.05) and 7 (141 and 166%, r<0.05).

CONCLUSION

Short term use of ticlopidine in patients with NSTEACS treated with aspirin and unfractionated heparin was associated with lower levels of TAT and fibrinogen (relative to control group) on day 14. This could be interpreted as delayed effect of ticlopidine on thrombin activity. Both ticlopidine and clopidogrel used in regimes with loading doses in NSTEACS patients treated with aspirin and antithrombin prevented acute phase elevation of vWF.

[The anticoagulant properties of the endothelium studied by the standard venous occlusion test]

Venous occlusion (VO) during which thrombin (Th) is postulated to be generated is routinely used for evaluation of fibrinolytic potential of endothelium (E). This study was performed to find out whether VO can also be used for assessment of anticoagulant function of E. VO was performed in 98 male patients (pts) with ischemic heart disease. Levels of protein C (PrC) which is related to Th binding by thrombomodulin and fibrinopeptide A (FpA)--a marker of presence of free Th--were determined together with some other factors of coagulation and fibrinolysis. Differences between pre- and postVO PrC levels fluctuated from -54.8% to +57.3%. According to reaction of PrC to VO pts were divided into 2 groups: 13 pts with increase or no change and 17 pts with decrease (consumption) of PrC. In pts without PrC consumption there was a significant increase in FpA. In pts with PrC consumption FpA was unchanged. In pts with PrC consumption exceeding its median value for this group (14%) PAI-1 antigen level fell significantly (-8.4 + 4%) during VO. Thus PrC consumption after VO indicates that TH is effectively removed from blood stream by endothelial factors. Absence of consumption of PrC is a sign of ineffective anticoagulant function of E. Increase in PrC level during VO in some pts may be due to its escape from tissue depot.

[Tissue plasminogen activator, its inhibitor and other factors of the blood fibrinolytic system in stable coronary heart disease]

The activity of tissue plasminogen activator (TPA), its rapid inhibitor (TPAL), C protein (Cp), plasminogen, alpha 2-antiplasmin, antithrombin III was evaluated and the levels of fibrinogen-fibrin degradation products and fibrinogen (F) were measured in 51 males with persistent coronary heart disease (CHD) and 16 without coronary atherosclerosis and atherosclerosis of other sites, which were matched for age and CHD risk factors. The patients were found to have elevated TRAI levels (17.3 +/- 1.2 IU/ml versus 12.2 +/- 2.2 IU/ml in the controls; p less than 0.05), increased TPA release (75.5 +/- 9.2 IU/ml versus 47.5 +/- 7.9 IU/ml in the controls; p less than 0.03) in response to venous occlusion, and lower Cp levels (-7.7 +/- 2.5%; p less than 0.01). The level of F correlated with the severity of coronary atherosclerosis. The patients with primary angina pectoris displayed higher TPA release than did those with chronic CHD. The presented facts are associated with overt changes occurring in the response of the endothelium in the patients, primarily, in early CHD.

[Endogenous vasopressin and fibrinolysis in patients with angina pectoris]

A relationship was examined between blood vasopressin levels and the fibrinolytic system in 35 patients with angina pectoris (16 with vasospastic angina (VA) and 19 with exercise-induced angina) who had undergone vein occlusion testing. There was a positive correlation between the post-testing vasopressin levels and the activity of tissue plasminogen activator inhibitor (TPAI) (r = 0.54) which was more high in patients with VA (r = 0.61). Only did the patients with VA show a direct relationship between the vasopressin concentrations and the activity of tissue plasminogen activator (TPA) (r = 0.63), the concentration of fibrinogen-fibrin degradation products (FFDP) (r = 0.88). Thirteen patients having higher vasopressin levels (over 3.4 ng/ml) displayed a greater TPAI activity than did the patients with vasopressin levels of at least 3.4 ng/ml (26.2 +/- 4.9 and 15.0 +/- 1.42 IU/ml, respectively; p less than 0.05). There was a direct relationship between the vasopressin levels and the activity of TPA (r = 0.65), the concentration of FFDP (r = 0.78) in patients having a vasopressin level of above 3.4 ng/ml. The findings are in agreement with the concept that endogenous vasopressin is involved in the regulation of the blood fibrinolytic system.

[Unstable angina: tissue plasminogen activator, tissue plasminogen activator inhibitors, protein C and other factors of the blood fibrinolytic system]

The authors examined the activities of plasminogen activator, its inhibitor, the levels of C protein, antithrombin III, alpha 2-antiplasmin, plasminogen, fibrinogen, fibrinogen/fibrin degradation products in 22 patients with unstable angina by using the vein occlusive test. No significant differences were found in the examined parameters while comparing the group of stable angina patients and healthy subjects. It was concluded that thrombogenesis disturbances in unstable angina were regional and the recording of peripheral blood fibrinolytic parameters failed to detect any changes characteristic of unstable angina.

[Signs of thrombin formation in venous occlusion in patients with ischemic heart disease and the role of the protein C activation system in its utilization]

Elevated levels of fibrin peptide A were found in venous occlusion only in the patients unconsuming C protein, which indicates that there is a relationship between the thrombin production processes during venous occlusion and the C protein system functioning, the anticoagulant function of the endothelium in particular. Moreover, this makes it possible to employ the standard venous occlusion test to make an integral assessment of endothelial function.