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Giralt T, Ribas N, Freixa X, Sabaté M, Caldentey G, Tizón-Marcos H, Carrillo X, García-Picart J, Lidón RM, Cárdenas M, Pérez-Fernández S, Mauri J, Vaquerizo B. Impact of pre-angioplasty antithrombotic therapy administration on coronary reperfusion in ST-segment elevation myocardial infarction: Does time matter? Int J Cardiol 2020; 325:9-15. [PMID: 32991944 DOI: 10.1016/j.ijcard.2020.09.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/17/2020] [Accepted: 09/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal timing of antithrombotic therapy for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) is unclear. We analyzed the impact of pre-angioplasty administration of unfractionated heparin (UFH) on infarct-related artery (IRA) patency and mortality. METHOD Multicenter prospective observational study of 3520 STEMI patients treated with PPCI from 2016 to 2018. Subjects were divided into four groups according to the elapsed time from heparin administration to PPCI: Group 1: Upon arrival at catheterization laboratory or ≤ 30 min (n = 800; 22.7%); Group 2: 31 to 60 min (n = 994; 28.2%); Group 3: 61 to 90 min (n = 1091; 31%); Group 4: >90 min (n = 635; 18%). IRA patency was defined as thrombolysis in myocardial infarction (TIMI) flow grade 2-3. Multivariate analyses assessed factors associated with IRA patency and both 30-day and 1-year mortality. RESULTS UFH administration at STEMI diagnosis was an independent predictor of IRA patency especially when administered more than 60 min before the PPCI (OR 1.43; 95% CI 1.14-1.81), either an independent predictor of 30-day (HR 0.63; 95% CI 0.42-0.94) and 1-year (HR 0.57; 95% CI 0.41-0.80) mortality. The effect of UFH on IRA patency was higher when administered earlier from the symptom onset. CONCLUSION UFH administration at STEMI diagnosis improves coronary reperfusion prior to PPCI and this benefit seems associated with superior clinical outcomes. The presented results highlight a time-dependent effectiveness of UFH, since its reported effect is greater the sooner UFH is administered after symptom onset.
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Affiliation(s)
- Teresa Giralt
- Cardiology Department, Hospital del Mar, Passeig Marítim de la Barceloneta, 25-29, 08003 Barcelona, Spain; Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Medicine Department, Program in Medicine and Translational Investigation, Universitat de Barcelona, Barcelona, Spain.
| | - Núria Ribas
- Cardiology Department, Hospital del Mar, Passeig Marítim de la Barceloneta, 25-29, 08003 Barcelona, Spain; Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Medicine Department, Program in Medicine and Translational Investigation, Universitat de Barcelona, Barcelona, Spain; Medicine department, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Xavier Freixa
- Medicine Department, Program in Medicine and Translational Investigation, Universitat de Barcelona, Barcelona, Spain; Cardiovascular Institute, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Manel Sabaté
- Medicine Department, Program in Medicine and Translational Investigation, Universitat de Barcelona, Barcelona, Spain; Cardiovascular Institute, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Guillem Caldentey
- Cardiology Department, Hospital del Mar, Passeig Marítim de la Barceloneta, 25-29, 08003 Barcelona, Spain; Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Helena Tizón-Marcos
- Cardiology Department, Hospital del Mar, Passeig Marítim de la Barceloneta, 25-29, 08003 Barcelona, Spain; Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Catalan Health Service, Generalitat de Catalunya, AMI Code Registry, Barcelona, Catalonia, Spain
| | - Xavier Carrillo
- Cardiology Department, Hospital Germans Trias i Pujol, Badalona, Spain; Catalan Health Service, Generalitat de Catalunya, AMI Code Registry, Barcelona, Catalonia, Spain
| | - Joan García-Picart
- Cardiology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Catalan Health Service, Generalitat de Catalunya, AMI Code Registry, Barcelona, Catalonia, Spain
| | - Rosa Maria Lidón
- Cardiology Department, Hospital Vall d'Hebron, Barcelona, Spain; Catalan Health Service, Generalitat de Catalunya, AMI Code Registry, Barcelona, Catalonia, Spain
| | - Mérida Cárdenas
- Cardiology Department, Hospital Trueta de Girona, Barcelona, Spain; Catalan Health Service, Generalitat de Catalunya, AMI Code Registry, Barcelona, Catalonia, Spain
| | - Silvia Pérez-Fernández
- IMIM (Hospital del Mar Medical Research Institute), Cardiovascular Epidemiology and Genetics Group (EGEC), REGICOR Study Group, Barcelona, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - Josepa Mauri
- Cardiology Department, Hospital Germans Trias i Pujol, Badalona, Spain; Catalan Health Service, Generalitat de Catalunya, AMI Code Registry, Barcelona, Catalonia, Spain
| | - Beatriz Vaquerizo
- Cardiology Department, Hospital del Mar, Passeig Marítim de la Barceloneta, 25-29, 08003 Barcelona, Spain; Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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Bañeras J, Olivero C, Bosch M, Lidón RM, Barrabés J, García-Dorado D. Therapeutic Hypothermia, Propofol, and High Lactate Levels: A Suspicious Combination. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2018; 71:760-762. [PMID: 28606463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/11/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Jordi Bañeras
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Cora Olivero
- Servicio de Medicina Interna, Hospital de Terrassa, Terrassa, Barcelona, Spain
| | - Montserrat Bosch
- Servicio de Farmacología Clínica, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosa Maria Lidón
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Barrabés
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David García-Dorado
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Bañeras J, Olivero C, Bosch M, Lidón RM, Barrabés J, García-Dorado D. Hipotermia terapéutica, propofol y lactato elevado: una combinación sospechosa. Rev Esp Cardiol (Engl Ed) 2018. [DOI: 10.1016/j.recesp.2017.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bañeras J, Ferreira-González I, Marsal JR, Barrabés JA, Ribera A, Lidón RM, Domingo E, Martí G, García-Dorado D. Short-term exposure to air pollutants increases the risk of ST elevation myocardial infarction and of infarct-related ventricular arrhythmias and mortality. Int J Cardiol 2017; 250:35-42. [PMID: 29056239 DOI: 10.1016/j.ijcard.2017.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/25/2017] [Accepted: 10/02/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The relation between STEMI and air pollution (AP) is scant. We aimed to investigate the short term association between AP and the incidence of STEMI, and STEMI-related ventricular arrhythmias (VA) and mortality. METHODS The study was carried out in the area of Barcelona from January 2010 to December 2011. Daily STEMI rates and incidence of STEMI-related VA and mortality were obtained prospectively. The corresponding daily levels of the main pollutants were recorded as well as the atmospheric variables. Three cohorts were defined in order to minimize exposure bias. The magnitude of association was estimated using a time-series design and was adjusted according to atmospheric variables. RESULTS The daily rate of hospital admissions for STEMI was associated with increases in PM 2.5, PM 10, lead and NO2 concentrations. VA incidence and mortality were associated with increases in PM 2.5 and PM 10 concentrations. In the most specific cohort, BCN (Barcelona) Attended & Resident, STEMI incidence was associated with increases in PM 2.5 (1.009% per 10μg/m3) and PM 10 concentrations (1.005% per 10μg/m3). VA was associated with increases in PM 2.5 (1.021%) and PM 10 (1.015%) and mortality was associated with increases in PM 2.5 (1.083%) and PM 10 (1.045%). CONCLUSIONS Short-term exposure to high levels of PM 2.5 and PM 10 is associated with increased daily STEMI admissions and STEMI-related VA and mortality. Exposure to high levels of lead and NO2 is associated with increased daily STEMI admissions, and NO2 with higher mortality in STEMI patients.
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Affiliation(s)
- Jordi Bañeras
- Department of Cardiology, Vall d'Hebron Hospital, CIBERCV, Autonomous University of Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.
| | - Ignacio Ferreira-González
- Department of Cardiology, Vall d'Hebron Hospital, CIBERCV, Autonomous University of Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | | | - José A Barrabés
- Department of Cardiology, Vall d'Hebron Hospital, CIBERCV, Autonomous University of Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Aida Ribera
- Department of Cardiology, Vall d'Hebron Hospital, CIBERCV, Autonomous University of Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Rosa Maria Lidón
- Department of Cardiology, Vall d'Hebron Hospital, CIBERCV, Autonomous University of Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Enric Domingo
- Department of Cardiology, Vall d'Hebron Hospital, CIBERCV, Autonomous University of Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Gerard Martí
- Department of Cardiology, Vall d'Hebron Hospital, CIBERCV, Autonomous University of Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - David García-Dorado
- Department of Cardiology, Vall d'Hebron Hospital, CIBERCV, Autonomous University of Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
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Pérez-Rodon J, Doiny D, Miranda B, Rivas-Gandara N, Roca-Luque I, Francisco-Pascual J, Lidón RM, García-Dorado D, Moya Mitjans A. Life-threatening and life-saving inappropriate implantable cardioverter defibrillator shocks. Clin Case Rep 2017; 5:521-525. [PMID: 28396781 PMCID: PMC5378847 DOI: 10.1002/ccr3.893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 01/18/2017] [Accepted: 02/13/2017] [Indexed: 11/22/2022] Open
Abstract
An implantable cardioverter defibrillator (ICD) lead dislodgement into the right atrium is a dangerous situation, particularly in patients in atrial fibrillation because atrial fibrillation can be sensed as ventricular fibrillation and true ventricular fibrillation induced with an inappropriate shock. In the presence of shocks, ICD interrogation should be performed as soon as possible.
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Affiliation(s)
- Jordi Pérez-Rodon
- Department of Cardiology Arrhythmia Unit Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
| | - David Doiny
- Department of Cardiology Arrhythmia Unit Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
| | - Berta Miranda
- Department of Cardiology Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
| | - Nuria Rivas-Gandara
- Department of Cardiology Arrhythmia Unit Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
| | - Ivo Roca-Luque
- Department of Cardiology Arrhythmia Unit Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
| | - Jaume Francisco-Pascual
- Department of Cardiology Arrhythmia Unit Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
| | - Rosa Maria Lidón
- Department of Cardiology Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
| | - David García-Dorado
- Department of Cardiology Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
| | - Angel Moya Mitjans
- Department of Cardiology Arrhythmia Unit Hospital Universitari Vall d'Hebrón Universitat Autònoma de Barcelona Edifici Annexos, planta 9, Passeig Vall d'Hebrón, 119-129 08035 Barcelona Spain
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Figueras J, Domingo E, Ferreira I, Lidón RM, Garcia-Dorado D. Persistent angina pectoris, cardiac mortality and myocardial infarction during a 12 year follow-up in 273 variant angina patients without significant fixed coronary stenosis. Am J Cardiol 2012; 110:1249-55. [PMID: 22835410 DOI: 10.1016/j.amjcard.2012.06.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 06/08/2012] [Accepted: 06/08/2012] [Indexed: 10/28/2022]
Abstract
The incidence of cardiac events in patients with variant angina pectoris without significant coronary stenosis and ST-segment elevation was analyzed during a 12-year follow-up period in 273 consecutive patients (82% men) admitted from 1986 through 2010. Among the 252 patients who underwent electrocardiography during pain, 205 had ST-segment elevation (82%) and 45 had ST-segment depression (18%). During index hospitalization, angina occurred in 179 patients (66%), ventricular tachycardia or fibrillation in 28 (10%), and complete atrioventricular block in 3 (1%), but there were no deaths or myocardial infarctions (MIs). At 140 months, angina was still present in 129 patients (47%), but frequent angina (>10 episodes/year) occurred in only 6%. Total mortality, cardiac mortality, and MI rates were 24%, 7.0%, and 6%, respectively. Cardiac death or MI occurred in 28 patients (10%), associated with tobacco smoking (p = 0.004), antecedent "first-wind" angina (p = 0.020), and angina during hospitalization (p = 0.044) and with continued smoking (p = 0.056) and recurrent angina during follow-up (p <0.001). Multivariate analysis identified age (p = 0.001), antecedent infarction (p = 0.005), first-wind angina (p = 0.009), and smoking at index hospitalization (p = 0.027) as predictors of total mortality and treatment with calcium antagonists (p = 0.047) and smoking during follow-up (p = 0.110) for cardiac mortality and MI. In conclusion, during 12-year follow-up, patients with variant angina pectoris, mostly with ST-segment elevation during pain, had a reduced incidence of cardiac mortality and MI, associated with first-wind angina, persistent angina, and continued smoking.
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7
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Affiliation(s)
- Jaume Figueras
- Unitat Coronaria, Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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8
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Barrabés JA, Garcia-Dorado D, Mirabet M, Lidón RM, Soriano B, Ruiz-Meana M, Pizcueta P, Blanco J, Puigfel Y, Soler-Soler J. Lack of effect of glycoprotein IIb/IIIa blockade on myocardial platelet or polymorphonuclear leukocyte accumulation and on infarct size after transient coronary occlusion in pigs. J Am Coll Cardiol 2002; 39:157-65. [PMID: 11755302 DOI: 10.1016/s0735-1097(01)01712-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We sought to assess the effect of glycoprotein (GP) IIb/IIIa blockade on myocardial platelet and polymorphonuclear leukocyte accumulation and on infarct size after coronary injury and transient coronary occlusion (CO) in pigs. BACKGROUND It has been suggested that platelet GP IIb/IIIa blockade might reduce the severity of microvascular damage after reperfusion. METHODS Sixteen thiopental-anesthetized, open-chest pigs, in whom platelets had been labeled with technetium-99m (99mTc) on the previous day, were submitted to catheter-induced left anterior descending coronary artery (LAD) injury followed by 55 min of CO and 5 h of reperfusion. Five minutes before reflow, the animals were blindly allocated to receive lamifiban (intravenous bolus of 250 microg/kg body weight and continuous infusion of 3 microg/kg per min) or saline. RESULTS Lamifiban had a rapid and potent platelet anti-aggregatory effect, as demonstrated by significant prolongation of the bleeding time and profound (approximately 90%) inhibition of ex vivo platelet aggregation, and completely prevented the development of cyclic flow reductions of the LAD (0 vs. 5 +/- 1, one of them followed by re-occlusion, in control animals, p = 0.005). However, compared with animals receiving placebo, those treated with lamifiban had a similar (p = NS) content of (99m)Tc platelets in the reperfused myocardium (288 +/- 40% vs. 205 +/- 27% of the value in the control region, respectively) and similar myeloperoxidase activity (0.50 +/- 0.17 U/g vs. 0.47 +/- 0.17 U/g, respectively) and infarct size (46.8 +/- 12.0% vs. 49.8 +/- 10.5% of the area at risk, respectively). Arteriolar platelet thromboemboli were very rarely seen on histologic analysis. Lamifiban did not modify platelet P-selectin expression in additional studies. CONCLUSIONS Platelet GP IIb/IIIa blockade has a potent antithrombotic effect at the culprit lesion, but does not significantly reduce the magnitude of microvascular platelet accumulation or myocardial damage after transient CO.
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Affiliation(s)
- José A Barrabés
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Figueras J, Monasterio Y, Lidón RM, Nieto E, Soler-Soler J. Thrombin formation and fibrinolytic activity in patients with acute myocardial infarction or unstable angina: in-hospital course and relationship with recurrent angina at rest. J Am Coll Cardiol 2000; 36:2036-43. [PMID: 11127437 DOI: 10.1016/s0735-1097(00)01023-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The goal of this study was to investigate possible differences in thrombin generation or fibrinolytic capacity in patients with unstable angina (UA) or acute myocardial infarction (AMI) with or without recurrent angina at rest. BACKGROUND Angina at rest in patients with AMI or UA is generally produced by a reduction in coronary flow, but it is unclear whether patients with or without this event differ in their thrombin generation or in their fibrinolytic capacities, which might influence the course of the culprit lesion. METHODS Thrombin-antithrombin complex (TAT), D-dimer, fibrinogen and plasminogen activator inhibitor (PAI-1) antigen plasma levels were determined in 40 patients with AMI and in 23 with UA on admission, at 10 days and at three months. RESULTS First day values for TAT, fibrinogen and D-dimer were comparable in patients with AMI and in those with UA. At 10 days they increased significantly in each group, and at 3 months they decreased to a similar extent. First day PAI-1 levels, however, were highest in both groups and declined in AMI patients at 10 days and at three months, whereas they also decreased at 10 days in UA patients but not any further at three months. Ten patients with AMI (25%) and 12 with UA (52%) developed in-hospital angina at rest. First day values for TAT, fibrinogen and D-dimer were similar in patients with or without angina, but PAI-1 levels were higher in the former subset (p < 0.008). At 10 days, however, TAT (p < 0.013) and D-dimer (p < 0.013) were higher in patients who developed angina than in those who did not. CONCLUSIONS The higher inhibition of fibrinolytic activity in the first day in patients with AMI or UA who will develop recurrent angina suggests that maintenance of a prothrombotic status may contribute to its mechanisms, perhaps by preventing passivation of the culprit thrombus/plaque. This is consistent with greater thrombin generation and greater levels of fibrynolitic products at 10 days observed in these patients compared with those who attain early stability.
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Affiliation(s)
- J Figueras
- Unitat Coronària, Servei de Cardiologia, Hospital General Vall d'Hebron, Barcelona, Spain.
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Heras M, Fernández Ortiz A, Gómez Guindal JA, Iriarte JA, Lidón RM, Pérez Gómez F, Roldán I. [Practice guidelines of the Spanish Society of Cardiology. Recommendations for the use of antithrombotic treatment in cardiology]. Rev Esp Cardiol 1999; 52:801-20. [PMID: 10563156 DOI: 10.1016/s0300-8932(99)75009-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The indications for the use of antithrombotic therapy are evolving as new drugs become available or new indications or dosages are recommended for drugs already in use. This document reviews and updates the former one published in 1994. To that end, an exhaustive revision of the literature published in the last 15 years has been undertaken. Following the evidence based medicine dictates, and aiming to select all the relevant publications for each pathology, all studies were selected through MEDLINE, using the specified key words for each subject, and were filtered using the following steps: a) only randomized, controlled studies, meta-analysis, guidelines and review articles were chosen; b) then, the Best-Evidence and Cochrane Collaboration databases were consulted; c) finally, the evidence based medicine validation, relevance and applicability criteria were assessed for each publication. The use of antiaggregants and anticoagulants are given for the following conditions: a) prevention of deep vein thrombosis and pulmonary embolism; b) prevention of systemic emboli in patients with lone atrial fibrillation, atrial fibrillation associated or not with rheumatic heart disease, in patients with biological or mechanical cardiac valvular prostheses and in dilated cardiomyopathy; c) antithrombotic therapy in coronary heart disease and in coronary intervention; d) the interactions with oral anticoagulants and how to control these therapies are also discussed.
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Affiliation(s)
- M Heras
- Institut de Malalties Cardiovasculars, Hospital Clínic, Barcelona.
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Lidón RM. [Persistent activation and/or reactivation in the subacute phase of unstable angina. Reasons for prolonged antithrombotic treatment]. Rev Esp Cardiol 1999; 52 Suppl 1:90-6. [PMID: 10364818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Coronary artery thrombosis, due to a rupture of the vulnerable plaque, plays an important role in acute coronary syndromes. The interaction between platelets and thrombin with ruptured vulnerable plaque trigger a complex mechanism. The clinical manifestations depend on the extent and duration of thrombus formation. In the acute phase, aspirin, heparin and the new drugs reduce ischemic clinical outcomes. However, clinical rebound after withdrawal antithrombotic therapy has been observed and, follow-up studies have also documented a high risk of recurrence in the following months. A hypercoagulable state, thrombin generation and activation and haematological rebound is shown in acute coronary syndrome patients. Thus, the goal of treatment could be to control thrombotic response in the acute phase and to allow the healing and stabilization of the culprit lesion to avoid clinical ischemic events in the long-term.
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Affiliation(s)
- R M Lidón
- Servei de Cardiologia, Hospital Vall d'Hebron, Barcelona.
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Barrabés JA, Garcia-Dorado D, Oliveras J, González MA, Ruiz-Meana M, Solares J, Burillo AG, Lidón RM, Antolín M, Castell J, Soler-Soler J. Intimal injury in a transiently occluded coronary artery increases myocardial necrosis. Effect of aspirin. Pflugers Arch 1996; 432:663-70. [PMID: 8764967 DOI: 10.1007/s004240050183] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study tested the hypothesis that intimal injury in a transiently occluded coronary artery limits myocardial salvage. The effect of intimal injury on reactive hyperaemia was investigated in 17 pigs submitted to a 30-min occlusion of the left anterior descending coronary artery (LAD), not resulting in myocardial infarction. Catheter-induced intimal damage increased local platelet deposition (99mTc) and reduced hyperaemia, but did not modify myocardial platelet or polymorphonuclear leucocyte content (myeloperoxidase activity) after 6 h reperfusion. To investigate the influence of intimal injury on the extent of myocardial necrosis secondary to a more prolonged coronary occlusion, and the role of platelets on this influence, 52 pigs were submitted to a double randomization (2x2 factorial design) to 250 mg i.v. aspirin vs. placebo and to coronary intimal injury vs. no coronary damage before a 48-min occlusion of the LAD and 6 h of reperfusion. After excluding 12 animals with reocclusion, coronary intimal injury was associated with larger infarcts (triphenyltetrazolium reaction) in animals receiving placebo (36.2+/-7.0% of the area at risk in animals with intimal injury vs. 10.8+/-3.9% in animals without coronary injury, P=0.006) but not in those receiving aspirin (20.3+/-6.5 vs. 21.7+/-6.5% of the area at risk in animals with and without intimal injury respectively). These results suggest that coronary intimal injury in the reperfused artery may have adverse effects on myocardial salvage by mechanisms other than reocclusion or embolization of platelet aggregates.
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Affiliation(s)
- J A Barrabés
- Servicio de Cardiología, Hospital General Universitario Vall d'Hebron, Pg. Vall d'Hebron 119-129, E-08035 Barcelona, Spain
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Abstract
BACKGROUND The objective of this study was to investigate in patients with unstable angina and significant coronary stenosis (> 70%) whether or not the morning peak of myocardial ischemia is associated with a reduction in the ischemic threshold. The morning increased incidence of ischemic episodes in stable angina appears to be attributable to a coincidence of several factors. Patients with unstable angina who remain at bed rest, however, also present a similar morning increased incidence of ischemia, but its mechanisms are not completely understood. METHODS AND RESULTS The ischemic threshold was assessed by atrial pacing at 7 to 8 AM and at 12 to 1 PM in 46 patients. In the 34 with a positive pacing response (ST segment shift > 1.0 mm), ischemic threshold was lower at 7 to 8 AM than at 12 to 1 PM (131 +/- 16 versus 139 +/- 15 beats per minute, P < .001), whereas in the remaining 12 patients, the pacing response was negative. Moreover, 4 patients presented ST segment elevation during pacing in the morning but only 1 at noon and at a higher threshold. Baseline heart rate and diastolic blood pressure were higher at noon than in the morning (81 +/- 16 versus 76 +/- 13 beats per minute, P < .01, and 87 +/- 11 versus 82 +/- 10 mm Hg, P < .05). CONCLUSIONS The morning lowering of ischemic threshold in the absence of increases in baseline blood pressure or heart rate suggests that a reduced coronary vasodilator capacity or an increased coronary tone may favor the increased incidence of ischemic events during this interval.
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Affiliation(s)
- J Figueras
- Unitat Coronària, Hospital General Vall d'Hebron, Barcelona, Spain
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14
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Figueras J, Lidón RM. Circadian rhythm of angina in patients with unstable angina: relationship with extent of coronary disease, coronary reserve and ECG changes during pain. Eur Heart J 1994; 15:753-60. [PMID: 8088263 DOI: 10.1093/oxfordjournals.eurheartj.a060582] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A circadian distribution of ischaemic events has been identified in ambulatory patients with stable angina. However, whether a similar distribution occurs in patients with unstable angina who remain at bed rest is still uncertain. Therefore, we analysed the possible circadian presentation of episodes of angina at rest (n = 1222) in 193 patients hospitalized consecutively. The influence of extent of coronary disease (number of vessels with > 70% stenosis, 0, 1 and 2-3), type of ECG changes during pain on a 12-lead ECG, and coronary reserve, as assessed by ischaemic threshold (atrial pacing), were also evaluated. There were two peaks of highest incidence: at 0700-1000h and at 1900-2200h (P < 0.0001) which were unrelated to the extent of coronary disease, coronary reserve or type of ECG change. Patients with 1 or 2-3 vessel disease with a reduced ischaemic threshold (= < 150 beats.min-1), however, had a higher incidence of midnight angina (2300-0200h) than those with a normal threshold or with no vessel disease (P < 0.001). It is concluded that, in spite of being at bed rest, patients with unstable angina present a definite circadian distribution of angina, with peaks in the early morning and late evening. Patients with a low coronary reserve seem to have a higher incidence of midnight angina than others.
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Affiliation(s)
- J Figueras
- Unitat Coronaria, Hospital General Vall d'Hebrón, Barcelona, Spain
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15
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Abstract
Nitroglycerin provides an external source of nitric oxide which stimulates guanylate cyclase and produces vasodilatation and inhibition of platelet function. The antithrombotic effects of intravenous nitroglycerin were recently documented in various experimental models and in patients with unstable angina. This protocol was designed to evaluate whether these effects could also be detected with transdermal nitroglycerin in patients with stable angina. In a randomized, double-blind, controlled parallel trial, 22 patients received transdermal nitroglycerin, 0.6 mg/hour (11 patients), or placebo (11 patients). Platelet aggregation to adenosine diphosphate (ADP) and to thrombin was measured in whole blood. Thrombus formation was assessed on porcine aortic media exposed to the patient's venous blood for 3 minutes at shear rates of 2,546 and 754 s-1. Platelet aggregation to ADP decreased from 7.7 +/- 0.8 to 5.3 +/- 0.8 ohms (p < 0.05) with nitroglycerin, and to thrombin from 15.6 +/- 1.2 to 12 +/- 1.2 ohms (p < 0.05). Thrombus size at the high-shear rate decreased from 2.8 +/- 0.7 to 1.0 +/- 0.3 microns 2 (p < 0.05), and at the low-shear rate from 2.5 +/- 0.5 to 1.0 +/- 0.2 microns 2 (p < 0.05). Placebo had no significant effect on platelet aggregation and platelet thrombus deposition. These parameters were all reduced by > or = 20% in 8 patients taking nitroglycerin but only in 3 patients taking placebo (p < 0.05). Transdermal nitroglycerin significantly inhibits platelet aggregation and mural thrombus formation in patients with angina pectoris.
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Affiliation(s)
- L L Lacoste
- Department of Medicine, Montreal Heart Institute, Quebec, Canada
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16
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Lidón RM, Théroux P, Lespérance J, Adelman B, Bonan R, Duval D, Lévesque J. A pilot, early angiographic patency study using a direct thrombin inhibitor as adjunctive therapy to streptokinase in acute myocardial infarction. Circulation 1994; 89:1567-72. [PMID: 8149522 DOI: 10.1161/01.cir.89.4.1567] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The success of streptokinase in acute myocardial infarction is hampered by the high failure rate to achieve early reperfusion. This study evaluates the possible benefit of Hirulog (Biogen, Cambridge, Mass), a direct thrombin inhibitor, as adjunct therapy to streptokinase to enhance early patency and prevent rethrombosis. Heparin has been shown to be of very limited benefits in this setting. METHODS AND RESULTS Forty-five patients were randomized to Hirulog or heparin (2:1 ratio). Coronary angiography documented a TIMI 2 or 3 flow after 90 minutes in 77% of the patients treated with Hirulog and streptokinase and in 47% of patients treated with heparin and streptokinase (P < .05) and after 120 minutes in 87% and 47% of patients, respectively (P < .01). TIMI 3 flow was established in 77% of patients with Hirulog compared with 40% with heparin (P < .02). The clinical outcome and the bleeding rate was also favorable to Hirulog; no reocclusion was observed at late angiography performed 4.7 days later. CONCLUSIONS Hirulog in this pilot study significantly improved the early patency rate of the infarct-related artery with a favorable clinical profile. This new direct thrombin inhibitor exhibits promise as adjunctive therapy to thrombolysis.
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Affiliation(s)
- R M Lidón
- Department of Medicine, Montreal Heart Institute, Quebec, Canada
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17
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Lidón RM, Ariza A. [Heart failure, changes in heart rhythm, and cardiogenic shock in a 46-year-old patient]. Med Clin (Barc) 1993; 101:789-94. [PMID: 8114541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- R M Lidón
- Servicio de Cardiología, Ciutat Sanitària i Universitària Vall d'Hebron, Barcelona
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18
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Abstract
Heparin effectively prevents the complications of unstable angina but disease reactivation has been documented following its discontinuation. To investigate whether this could be related to antithrombin-III depletion, 50 patients with unstable angina had serial determinations of activated partial thromboplastin time and of the plasma levels of heparin, antithrombin-III activity and of the thrombin-antithrombin-III complex before, during and, in a subgroup of 8 patients, 4 hours after heparin discontinuation. Heparin was administered intravenously at therapeutic doses for a mean of 7.6 +/- 4.1 days. Plasma antithrombin-III activity decreased rapidly from 1.05 +/- 0.03 to 1.0 +/- 0.03 U/ml (p < 0.03) following heparin initiation with no further significant subsequent decrease. Antithrombin-III activity returned to the control values 4 hours after the discontinuation of heparin. Thus, heparin treatment is associated with small, non-cumulative and rapidly reversible decrease in antithrombin-III activity. Reactivation of unstable angina after discontinuation of heparin must be explained by a mechanism other than antithrombin-III deficiency.
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Affiliation(s)
- R M Lidón
- Department of Medicine, Montreal Heart Institute, Quebec, Canada
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19
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Lidón RM, Théroux P, Juneau M, Adelman B, Maraganore J. Initial experience with a direct antithrombin, Hirulog, in unstable angina. Anticoagulant, antithrombotic, and clinical effects. Circulation 1993; 88:1495-501. [PMID: 8403297 DOI: 10.1161/01.cir.88.4.1495] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Currently available antithrombotic therapy for unstable angina is unwieldy and occasionally ineffective. This study was designed to investigate the potential of Hirulog, a new synthetic specific antithrombin agent, for the management of this condition. METHODS AND RESULTS A total of 55 patients in the acute phase of unstable angina received intravenous Hirulog according to one of two protocols. In an acute dose-escalating study, 0.02, 0.05, 0.1, 0.25, and 0.5 mg.kg-1 x h-1, each for 30 minutes, were infused in 15 patients. Prolongation of activated partial thromboplastin time (aPTT) (r = .95), fibrinopeptide A inhibition (r = .96), and Hirulog plasma levels (r = .91) correlated closely with the dose infused, with significant changes compared with baseline appearing at doses of 0.25 mg.kg-1 x h-1 and higher. The purposes of the second protocol were to determine whether the anticoagulant and antithrombotic effects of the drug were sustained during a 72-hour infusion and to assess whether such treatment prevented the complications of unstable angina. Based on the initial study, we planned to give a dose of 0.25 mg.kg-1 x h-1 to each patient until 2 patients failed therapy, then successively higher doses until a 95% success rate was achieved or adverse effects intervened, increasing the dose after two failures had occurred at each level. Five patients received the 0.25-mg.kg-1 x h-1 dose and 14 the 0.5-mg.kg-1 x h-1 dose before two failures occurred. Failure was observed in only one of 21 patients at the dose of 1 mg.kg-1 x h-1. aPTT (+/- SEM) levels increased to 62 +/- 5, 76 +/- 2, and 98 +/- 3 seconds at the three doses, with minimal intraindividual variation, and Hirulog plasma levels to 1050, 2100, and 4200 mg/mL, respectively. Fibrinopeptide A plasma levels decreased at all doses but more consistently at the dose of 1 mg.kg-1 x h-1. The overall clinical success rate was 87.5%: 60% (3/5) at the low dose, 86% (12/14) at the intermediate dose, and 95% (20/21) at the high dose. No deaths, myocardial infarctions, or bleeding complications occurred. CONCLUSIONS In unstable angina patients, Hirulog infusions quickly and reproducibly yield stable, dose-dependent anticoagulant and antithrombotic effects with a favorable clinical efficacy profile.
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Affiliation(s)
- R M Lidón
- Department of Medicine, Montreal Heart Institute, Quebec, Canada
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20
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Abstract
To examine whether increases in heart rate might be a common trigger of angina at rest, changes in heart rate, blood pressure and rate-pressure product during pain were compared with the ischaemic threshold (heart rate with ST segment shift > = 1 mm), determined by atrial pacing, in 272 patients with unstable angina. During an average of 5.9 +/- 5.2 episodes of angina, heart rate was comparable to control values (77.0 +/- 14.5 vs 75.2 +/- 11.5, beats.min-1, ns) and significantly lower than the ischaemic threshold (147.9 +/- 22.9, P < 0.00001). The rate-pressure product was also lower (955 +/- 183 vs 2033 +/- 369, x 10, P < 0.00001). Heart rate during rest angina was lower than the ischaemic threshold even when we considered only patients with ST depression during pain (n: 71, 81.4 +/- 16.0 vs 132.8 +/- 21.4, P < 0.00001), those with three-vessel disease (n: 43, 79.9 +/- 15.9 vs 136.9 +/- 22.0, P < 0.00001), or those with a low ischaemic threshold (= < 130 beats.min, n: 78, 77.0 +/- 14.9 vs 118.3 +/- 10.7, P < 0.00001). In 154 patients in whom a second pacing test was performed the response was reproducible in 137 cases (89%). Thus, heart rate barely changes during angina at rest in patients with unstable angina and is consistently much lower than the ischaemic threshold. These findings support the concept that increases in heart rate are an unlikely trigger of ischaemia at rest, even in patients with markedly reduced coronary reserve.
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Affiliation(s)
- J Figueras
- Unitat Coronaria, Hospital General Vall d'Hebron, Barcelona, Spain
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21
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Affiliation(s)
- P Théroux
- University of Montreal, Quebec, Canada
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22
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Figueras J, Lidón RM. In-hospital prognostic relevance of a reduced ischemic threshold. Studies in 357 consecutive patients with acute coronary syndromes. Chest 1993; 103:871-7. [PMID: 8449084 DOI: 10.1378/chest.103.3.871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
In 357 patients with unstable coronary syndromes, a reduced pacing ischemic threshold (1-mm ST-segment depression at a heart rate < or = 150 beats per minute) was an independent predictor of main in-hospital events (death, myocardial infarction, or coronary surgery), which occurred in 33 percent (65/200) of the patients with a reduced threshold and in 8 percent (13/157) of those with a normal threshold (p < 0.0001). The incidences of death and infarction in patients with a normal (> 150 beats per minute), modestly reduced (140 to 150 beats per minute), or severely reduced (< or = 130 beats per minute) threshold were progressively higher (1 percent and 4 percent; 3 percent and 12 percent; and 7 percent and 18 percent respectively; p < 0.01). Thus, a reduced coronary reserve is associated with a fourfold increase in in-hospital complications; and when the reserve is severely curtailed, there may be a sevenfold increase in mortality.
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Affiliation(s)
- J Figueras
- Unitat Coronaria, Servei de Cardiologia, Hospital General Vall d'Hebron, Barcelona, Spain
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23
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Figueras J, Lidón RM. Coronary reserve, extent of coronary disease, recurrent angina and ECG changes during pain in the in-hospital prognosis of acute coronary syndromes. Eur Heart J 1993; 14:185-94. [PMID: 8449194 DOI: 10.1093/eurheartj/14.2.185] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The prognostic value of recurrent angina, severity of coronary disease, ECG changes during pain and coronary reserve (ischaemic threshold measured by atrial pacing: heart rate with ST segment shift = 1 mm), was evaluated in 383 consecutive patients with acute coronary syndromes. Univariate analysis showed a significant relationship between occurrence of complications (death, infarction or coronary surgery) and number of anginal episodes, extent of coronary disease, ischaemic threshold and ST depression with pain. A multivariate analysis indicated that the first three parameters were the main independent predictors. Coronary reserve was reduced (threshold < or = 150 beats.min-1) in 83% of patients who had a myocardial infarction (40), in 91% of those who died (11), in 87% of those who underwent coronary surgery (52) and in 47% of uncomplicated cases (301). Also, a low ischaemic threshold was associated with a larger number of anginal episodes than a high threshold (< or = 130 beats.min-1, 6.1 +/- 5.6 vs > 150 beats.min-1, 2.9 +/- 4.1, P < 0.0001), and in complicated patients with one-, two- or three-vessel disease ischaemic threshold (137.3 +/- 21.2, 133.3 +/- 18.9, and 135.1 +/- 21.2 beats.min-1, respectively) was lower than in the uncomplicated ones (153.4 +/- 20.1, P < 0.005; 148.2 +/- 19.1, P < 0.005; and 139.2 +/- 23.0 ns, beats.min-1). A threshold < 150 beats.min-1 and ECG changes during pain identified the subset with the highest risk for complications (59/137, 45%), whereas a threshold > 150 beats.min-1 and absence of pain or ECG changes during pain identified those with the lowest risk (5/109, 5%, P < 0.001). Thus, our findings document the prognostic significance of coronary reserve for in-hospital complications in patients with acute coronary syndromes and confirm the prognostic value of previously known risk markers. They also indicate that some of them may be significantly influenced by the status of coronary reserve.
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Affiliation(s)
- J Figueras
- Unitat Coronaria, Hospital General Vall d'Hebron, Barcelona, Spain
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24
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Abstract
The haemodynamic effects of a single dose of intravenous molsidomine were assessed in 12 patients with severe coronary disease. The investigation was carried out at rest during angina induced by pacing and after molsidomine during pacing at the rate at which angina had been produced. During angina, left ventricular systolic and end-diastolic pressure rose, left ventricular stroke work fell and coronary flow and myocardial oxygen consumption increased by 58.3% above the control levels. After the administration of molsidomine, atrial stimulation was not followed by angina and there were no significant changes in systolic blood pressure. Left ventricular end-diastolic pressure fell sharply and coronary flow and myocardial oxygen consumption were only 38% and 33% higher, respectively, than the control levels. The beneficial effects of molsidomine in ischaemic heart disease, therefore, are the result of peripheral vasodilation which, by reducing the preload and afterload, lowers the oxygen requirements of the myocardium and thus increase the threshold for angina. A direct action on the coronary network can not be excluded but if such an action does exist it must be very small in the light of the marked systemic effect.
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25
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Lidón RM, Augé JM, Crexells C, Oriol A. [Complications attributable to hemodynamic studies with coronariography, with special reference to ventricular fibrillation]. Rev Esp Cardiol 1984; 37:240-3. [PMID: 6473866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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