This sub-study of the Integrilin and Tenecteplase in Acute Myocardial Infarction (INTEGRITI) trial evaluated of the impact of combination reperfusion therapy with reduced-dose tenecteplase plus ...eptifibatide on continuous ST-segment recovery and angiographic results.
Combination therapy with reduced-dose fibrinolytics and glycoprotein IIb/IIIa inhibitors for ST-segment elevation myocardial infarction improves biomarkers of reperfusion success but has not reduced mortality when compared with full-dose fibrinolytics.
We evaluated 140 patients enrolled in the INTEGRITI trial with 24-h continuous 12-lead ST-segment monitoring and angiography at 60 min. The dose-combination regimen of 50% of standard-dose tenecteplase (0.27 μg/kg) plus high-dose eptifibatide (2 boluses of 180 μg/kg separated by 10 min, 2.0 μg/kg/min infusion) was compared with full-dose tenecteplase (0.53 μg/kg).
The dose-confirmation regimen of reduced-dose tenecteplase plus high-dose eptifibatide was associated with a faster median time to stable ST-segment recovery (55 vs. 98 min, p = 0.06), improved stable ST-segment recovery by 2 h (89.6% vs. 67.7%, p = 0.02), and less recurrent ischemia (34.0% vs. 57.1%, p = 0.05) when compared with full-dose tenecteplase. Continuously updated ST-segment recovery analyses demonstrated a modest trend toward greater ST-segment recovery at 30 min (57.7% vs. 40.6%, p = 0.13) and 60 min (82.7% vs. 65.6%, p = 0.08) with this regimen. These findings correlated with improved angiographic results at 60 min.
Combination therapy with reduced-dose tenecteplase and eptifibatide leads to faster, more stable ST-segment recovery and improved angiographic flow patterns, compared with full-dose tenecteplase. These findings question the relationship between biomarkers of reperfusion success and clinical outcomes.
Background: The aim of this present prospective study was to investigate the accuracy of cardiac markers for the prediction of subsequent cardiac events (cardiac death, acute myocardial infarction ...and recurrent ischemia requiring coronary revascularization).
Methods: Fibrinogen, cardiac troponin T, troponin I, creatine phosphokinase myocardial fraction, C-reactive protein and myoglobin at baseline and after 6 h were measured on 154 patients (109 male, 63±11 years) with chest pain. Receiver operator characteristic analyses were performed to determine cut-off points of cardiac markers in prediction of adverse events.
Results: The following cut-off values for prediction of cardiac events were calculated: troponin I at baseline 0.3 ng/ml (predictive accuracy=0.870), troponin I at 6 h 0.50 ng/ml (p.a.=0.909); troponin T at baseline 0.05 ng/ml (p.a.=0.643), troponin T at 6 h 0.05 ng/ml (p.a.=0.612), creatine phosphokinase myocardial fraction at baseline 2.0 ng/ml (p.a.=0.721), creatine phosphokinase myocardial fraction at 6 h 2.5 ng/ml (p.a.=0.734), myoglobin at baseline 23 ng/ml (p.a.=0.623), myoglobin at 6 h 26 ng/ml (p.a.=0.617), C-reactive protein at baseline 0.31 mg/dl (p.a.=0.662), C-reactive protein at 6 h 0.55 mg/dl (p.a.=0.682), and fibrinogen at baseline 360 mg/dl (p.a.=0.701). The combination of baseline troponin I with different parameters resulted in a higher sensitivity of up to 98%, with a similar predictive accuracy, but a lower specificity. Additive measurements of cardiac troponin I at 6 h to baseline cardiac troponin T and I proved to be the best combination for prediction of subsequnt cardiac events.
Conclusions: Changes in cut-off levels of cardiac markers and inflammatory parameters results in a high accuracy of risk stratification in patients with chest pains. Combination of these measurements might further help in the identification of patients who would benefit from early coronary revascularization.
Objectives: To examine by retrospective analysis of data from the FLEXI-CUT monocentre registry whether atherectomy can effectively simplify complex stent implantation in ostial bifurcation lesions ...by reducing the procedure to stenting of the left anterior descending (LAD) or left circumflex (LCX) artery ostium alone. Patients and methods: All patients who had been enrolled in the prospective FLEXI-CUT study (directional atherectomy with adjunctive balloon angioplasty) were retrospectively analysed on the basis of significant LAD or LCX ostial stenosis (⩾ 70% stenosis) deriving from an undiseased left main stem. The primary combined end point was the rate of target lesion revascularisation (TLR) and binary restenosis; secondary end points were procedural success and major adverse cardiac events (MACE) at the six-month follow up. Results: Of 30 patients enrolled with significant LAD or LCX ostium stenosis, 29 were effectively treated with directional atherectomy (96.7% procedural success). All patients underwent single-vessel stenting procedures of solely the LAD or LCX ostium. At follow up, binary stenosis was 25% (6 of 24), TLR (angiographic plus clinical) 10.3% (3 of 29) and total MACE 6.9% (2 of 29). Conclusions: Directional atherectomy with single-vessel stenting procedures facilitates the interventional treatment of LAD and LCX ostium stenosis, and leads to remarkably low TLR and binary stenosis at follow up.
Objective: To compare the early and late outcomes of primary percutaneous transluminal coronary angioplasty (PTCA) with fibrinolytic treatment among diabetic patients with acute myocardial infarction ...(AMI). Design: Retrospective observational study with data obtained from prospective registries. Setting: Tertiary cardiovascular institution with 24 hour acute interventional facilities. Patients: 202 consecutive diabetic patients with AMI receiving reperfusion treatment within six hours of symptom onset. Interventions: Fibrinolytic treatment was administered to 99 patients, and 103 patients underwent primary PTCA. Most patients undergoing PTCA received adjunctive stenting (94.2%) and glycoprotein IIb/IIIa inhibition (63.1%). Main outcome measures: Death, non-fatal reinfarction, and target vessel revascularisation at 30 days and one year were assessed. Results: Baseline characteristics were similar in these two treatment groups except that the proportion of patients with Killip class III or IV was considerably higher in those treated with PTCA (15.5% v 6.1%, p = 0.03) and time to treatment was significantly longer (103.7 v 68.0 minutes, p < 0.001). Among those treated with PTCA, the rates for in-hospital recurrent ischaemia (5.8% v 17.2%, p = 0.011) and target vessel revascularisation at one year (19.4% v 36.4%, p = 0.007) were lower. Death or reinfarction at one year was also reduced among those treated with PTCA (17.5% v 31.3%, p = 0.02), with an adjusted relative risk of 0.29 (95% confidence interval 0.15 to 0.57) compared with fibrinolysis. Conclusion: Among diabetic patients with AMI, primary PTCA was associated with reduced early and late adverse events compared with fibrinolytic treatment.
This article summarizes the results of a number of new clinical trials, registries and meta-analyses in the field of cardiovascular medicine. Key presentations made at the annual meeting of the ...American College of Cardiology (ACC), held in Chicago, IL, USA from 29 March till first April 2008 are reported. The ACC meeting was accompanied by the SCAI (Society for Cardiovascular and Angiographic Interventions) Annual Scientific Sessions in Partnership with ACC i2 Summit. The data were presented by leading experts in the field with relevant positions in the trials, registries or meta-analyses. These comprehensive summaries should provide the readers with the most recent data on diagnostic and therapeutic developments in cardiovascular medicine.
Enhanced external counterpulsation (EECP) is a non-invasive outpatient treatment used for angina pectoris. In patients with intractable angina refractory to aggressive surgical and medical treatment, ...several novel strategies are considered including EECP, transmural laser revascularisation, and spinal cord stimulation. EECP produces an acute haemodynamic effect that is presumed to be similar to that produced by the invasive intra-aortic balloon pump. By applying a series of compressive cuffs sequentially from the calves to the thigh muscles upon diastole and rapidly deflating the cuffs in early systole, an increase in diastolic and decrease in systolic pressure is created. Although data indicate improvement in angina in patients undergoing EECP, the role of EECP in the treatment of angina pectoris has not yet been well defined. At present, EECP use should be limited to patients with debilitating (functional class III and IV) refractory angina pectoris who are not candidates for revascularisation, are symptomatic despite being on maximal antianginal pharmacotherapy, and have no contraindications to EECP use.
Summary Background The thrombolysis in myocardial infarction (TIMI) frame count was reported to reflect coronary blood flow and have prognostic value. However, such data in syndrome X was lacking. ...The purpose of this study was to examine the prognostic value of the TIMI frame count in syndrome X patients, compared with the normal population. Methods The TIMI frame count was measured in 2,049 consecutive patients referred for coronary angiography from March 2003 to February 2005. Results Among 308 patients with normal coronary angiograms, 44 undergoing the procedure for electrophysiologic studies or valvular heart disease surveys other than angina were designated normal controls. Another 155 patients with positive stress test results were diagnosed as syndrome X. Comparisons of the two groups showed that the syndrome X patients had higher frame counts in the left anterior descending artery (40.9 ± 15.7 vs. 47.8 ± 25.4; p < 0.05) and left circumflex artery (35.2 ± 11.7 vs. 42.0 ± 18.7; p < 0.05). A similar trend was found in the right coronary artery (29.3 ± 13.5 vs. 31.9 ± 15.9; p = 0.2). The TIMI frame count in each artery of the syndrome X group was related to the patients' variables (sex, age, and body mass index), clinical variables (medication use, diabetes, hypertension, hypercholesterolemia, smoking, and family history), and hemodynamic variables (aortic systolic blood pressure and left ventricular end-diastolic pressure). By multivariate analysis, the TIMI frame counts in all arteries were significantly higher in women and lower with angiotensin-converting enzyme inhibitor (ACEI) use (both p < 0.05). The frame count in the left anterior descending was associated with diuretics use ( p < 0.05). Conclusion Our TIMI frame count data confirm the presence of slow coronary flow in syndrome X patients, especially women. ACEI use shortens the counts in these patients, suggesting that ACEIs have the potential to correct the underlying hemodynamic defects in such patients.
Although there have been advances in the management of unstable angina/non-ST segment elevation myocardial infarction syndromes, the rate of cardiovascular mortality after discharge is still ...unacceptably high. With many therapeutic options available, the clinician is challenged to identify the safest and most effective treatment for long term survival of each individual patient
Non ST-segment elevation acute coronary syndromes (NSTE ACS) are the most frequent cause of admission to intensive care units. Early risk assessment and implementation of optimal treatment are of ...special importance in these patients. Previous studies have demonstrated that renal insufficiency is an independent risk factor in patients with cardiovascular disease.
To assess the effects of renal function on the course of treatment and prognosis in patients with NSTE ACS admitted to hospitals without on-site invasive facilities but with a possibility of immediate transfer to a reference centre with a catheterisation laboratory.
Twenty-nine community hospitals without on-site invasive facilities participated in the Krakow Registry of Acute Coronary Syndromes - a prospective, multicentre, web-based, observational registry. Renal insufficiency (RI) was defined as creatinine clearance (CrCl) <60 ml/min.
NSTE ACS was diagnosed in 1396 patients. Renal insufficiency was diagnosed in 34% of all patients. Only 17% of them had been diagnosed with RI prior to admission. Transfer for invasive treatment was undertaken in 10% of RI patients as compared to 16% of patients with CrCl >60 ml/min (NS). In-hospital mortality among patients remaining on conservative treatment in community hospitals was significantly higher among RI patients (4.0 vs. 0.6%; p <0.001). Thienopyridines were less frequently used in RI patients (46 vs. 54%; p <0.05). In-hospital mortality among RI patients remaining in community hospitals and treated conservatively was higher than among non-RI patients in each TIMI risk score group: 7.3 vs. 2.4% (p <0.05) in the high risk group, 4.1 vs. 1.4% (NS) in the moderate and 3.6 vs. 0% (p <0.001) in the low risk group. Multivariate logistic regression analysis identified reduced creatinine clearance and a history of heart failure as independent factors influencing mortality.
Renal insufficiency was present in one-third of NSTE ACS patients. Patients with renal insufficiency had worse clinical risk profile and received less aggressive treatment. Patients with NSTE ACS and renal insufficiency treated conservatively had higher in-hospital mortality. Renal insufficiency modifies mortality irrespective of the TIMI risk score. Creatinine clearance should be considered in modification of the TIMI risk score scale.
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