The patients presenting acute coronary syndrome without ST segment elevation can have a short and long-term risk of death or recurrent ischemic events. Therefore, the evaluation of risk is an ...essential step in the management of such patients. We report two cases – a 86-year-old male, and a 46-year-old one – with acute coronary syndrome with non-ST-segment elevation, showing the importance of risk assessment to determine management strategy. Two risk profile scores were used: TIMI score and GRACE score. Routine use of validated risk score may facilitate more appropriate tailoring of intensive therapies, but the clinical reasoning of the physician is essential to take right decisions.
Platelet glycoprotein IIb/IIIa receptor antagonists (GpRAs) are also associated with improved clinical outcomes in the setting of PPCI, with early delivery before the procedure improving the rate of ...epicardial patency at angiography, and conferring additional benefit. 7 Restoration of epicardial flow before the start of intervention is certainly associated with superior outcomes following PPCI, 8 and in this symposium Brodie has already discussed the facilitated approach with antecedent GpRAs, thrombolytic agents, or combined therapy. 9 Also in this symposium Prasad and Gersh have further emphasised the importance of looking beyond the epicardial vessel, to the microcirculation, in order to optimise outcomes. 10 Indeed, the clinical benefits of GpRAs may be partly mediated by improved microvascular perfusion. In the EMERALD (enhanced myocardial efficacy and recovery by aspiration of liberalized debris) study the PercuSurge GuardWire distal protection system (Medtronic, Santa Rosa, California, USA) used during PPCI less than six hours after presentation with STEMI did not improve angiographic perfusion scores, ST segment resolution, final infarct size, or clinical end points when compared to the results from a randomised control group. 16 Perhaps more surprising are the results of the recently presented AIMI study 17 where rheolytic thrombectomy (Angiojet, Possis) not only failed to improve the quality of reperfusion (despite a prior supportive study 18 ), but was also associated with a significant increase in mortality when compared with routine PPCI alone.
Use of proton pump inhibitor (PPI) reduces the risk of gastrointestinal (GI) bleeding, and is generally recommended for high GI risk patients taking nonsteroidal anti-inflammatory agents. Aspirin ...and/or anticoagulants have been identified as increasing the risk of GI bleeding, whereby use of PPI could reduce this risk. The use of PPI in routine practice is not well defined, especially in patients with acute coronary syndromes (ACS) who require one or several antithrombotic drugs.
We analyzed the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction (PROVE IT-TIMI) 22 trial database, which enrolled patients who had been hospitalized for ACS. Patients were to be treated with aspirin, and received clopidogrel and/or warfarin at the discretion of the treating physician. We analyzed the use of PPI at baseline, which was not specified in the protocol, according to prior known GI risk factors.
Of the 4162 patients enrolled, 781 (18.8%) received PPI during the course of this study. The use ranged from 14% to 67% across the number of GI risk factors of 0 to > or =4 (P < 0.0001). Individual factors most associated with increased use of PPI were a prior GI event (RR = 2.3, P < 0.001) and use of anticoagulants (RR = 1.49, P < 0.001), but not dual antiplatelet therapy.
Use of PPI following ACS is modest, although it did increase with an increasing number of previously identified GI risk factors. Further, larger studies are warranted to validate prior, or identify new, risk factors as predictors of long-term bleeding, and improve awareness of GI bleeding risk such that use of PPI could be optimized.
No difference in outcome was observed in patients presenting either <10 or >10 years after CABG. ...time from CABG does not affect outcome in patients with prior CABG treated with primary PCI for ...STEMI due to SVG occlusion. ...the large thrombotic burden markedly complicates the recanalisation of an occluded SVG. ...of graft age, mechanical reperfusion is often complicated by distal embolisation and no reflow, which is associated with a higher short- and long-term mortality. 1- 3 In elective patients with PCI treated for SVG disease, the Saphenous vein-graft Angiopathy Free of Emboli Randomized Trial showed significant improvement of angiographic outcome (TIMI 3 flow and no reflow), resulting in a reduction in myocardial infarctions, with the use of a distal embolic protection device compared with standard techniques. 5 Interestingly, a substudy of this trial showed that SVG age was not a predictor of clinical outcome, as in our study on patients with STEMI.
Background: Immediate risk stratification of patients with myocardial infarction in the emergency department (ED) at the time of initial presentation is important for their optimal emergency ...treatment. Current risk scores for predicting mortality following acute myocardial infarction (AMI) are potentially flawed, having been derived from clinical trials with highly selective patient enrolment and requiring data not readily available in the ED. These scores may not accurately represent the spectrum of patients in clinical practice and may lead to inappropriate decision making. Methods: This study cohort included 1212 consecutive patients with AMI who were admitted to the Mayo Clinic coronary care unit between 1988 and 2000. A risk score model was developed for predicting 30 day mortality using parameters available at initial hospital presentation in the ED. The model was developed on patients from the first era (training set—before 1997) and validated on patients in the second era (validation set—during or after 1997). Results: The risk score included age, sex, systolic blood pressure, admission serum creatinine, extent of ST segment depression, QRS duration, Killip class, and infarct location. The predictive ability of the model in the validation set was strong (c = 0.78). Conclusion: The Mayo risk score for 30 day mortality showed excellent predictive capacity in a population based cohort of patients with a wide range of risk profiles. The present results suggest that even amidst changing patient profiles, treatment, and disease definitions, the Mayo model is useful for 30 day risk assessment following AMI.
TIMI Risk Score for ST-elevation myocardial infarction (STEMI) was developed in a cohort of patients treated with fibrinolysis. It was though to predict in-hospital and short-term prognosis. Later ...studies validated this approach in large cohorts of patients, regardless of the applied treatment and presented its good power to predict 30-day mortality.
We applied the TIMI Risk Score to our registry of STEMI patients treated with primary percutaneous intervention (pPCI) to validate the possibility to predict one-year survival.
Our registry comprised 494 consecutive patients (mean age 58.5+/-11.3 years) with STEMI treated with pPCI who were followed for approximately one year. STEMI was diagnosed based on typical criteria: chest pain, ECG changes and rise in myocardial necrosis markers. In all patients TIMI Risk Score for STEMI was calculated and they were divided into three groups: low risk (0-5 points), medium risk (6-7) and high risk (>7 points). Multivariate logistic regression analysis, Kaplan-Meier survival analysis with Cox and log-rank tests as well as c statistics from receiver-operator curves (ROC) were used for statistical analysis.
TIMI 3 flow was obtained in 95.5% of patients. Median TIMI risk score was 4 (ranging from 0 to 10). During follow-up there were 47 deaths (9.5%). There was a statistically significant difference in survival between all risk groups both in 30-day and one-year follow-up (p <0.001 log-rank test). TIMI Risk Score had good power to predict 30-day (c statistic 0.834, 95% CI 0.757-0.91, p <0.0001) as well as one-year mortality (c statistic 0.809, 95% CI 0.739-0.878, p <0.0001). Interestingly, when we excluded from the analysis all patients who died during the first 30 days, TIMI Risk score maintained its very good prognostic value. All analysed risk groups significantly differed between each other with respect to mortality (p <0.05, log-rank test) and the c statistic was 0.745 (95% CI 0.612-0.879, p <0.0002). In multivariate logistic regression analysis TIMI Risk Score was one of the independent risk factors of death during one-year follow-up (OR 1.59, p <0.001).
TIMI Risk Score accurately defines the population of STEMI patients who are at high risk of death not only during the first 30 days, but also during a long-term follow-up. This simple score should be included in the discharge letters because it contains very useful information for further care.
TIMI Risk Score predicts early readmission Soiza, Roy L.; Hughes, Niall J.; Leslie, Stephen J. ...
International journal of cardiology,
08/2006, Letnik:
111, Številka:
2
Journal Article
Recenzirano
To assess if the TIMI Risk Score could predict early readmission.
869 consecutive admissions to a Scottish district general hospital with suspected acute coronary syndrome.
A computerised clinical ...information system was interrogated to verify readmission. Area under the receiver operator characteristic curve and chi-square test for trend between TIMI Risk Score and readmission rate were calculated.
Median follow up was 73 days. There was a strong association between TIMI Risk Score and readmission rate (chi-square test for trend,
p
<
0.001), with an area under the receiver operator characteristic curve of 0.60 (95% C.I. 0.55–0.65).
The TIMI Risk Score can predict readmission. This study reinforces its utility as a tool for identifying patients more likely to benefit from aggressive intervention.
Objective: To investigate serial assessments of systolic coronary flow reversal in the infarct related artery for predicting poor left ventricular functional recovery after reperfused acute ...myocardial infarction. Setting: Regional hospital. Patients and methods: 49 patients with anterior acute myocardial infarction had transthoracic Doppler echocardiography to record coronary flow velocity in the left anterior descending coronary artery immediately after successful primary coronary angioplasty (day 0), and at 48 hours, one week, and three weeks. Main outcome measures: Coronary flow velocity at each time point; regional wall motion score index (RWMSI) at day 0 and at three weeks. Irreversible dysfunction was defined as a decrease in RWMSI to < 0.22. Results: Measurements of coronary flow velocity could be made in 45 patients. Patients were divided into three groups: no systolic flow reversal (group 1, n = 27), systolic flow reversal observed only on day 0 (group 2, n = 8), and systolic flow reversal persisting until 48 hours (group 3, n = 10). Although baseline RWMSI was similar among the three groups, the value at three weeks was significantly higher in group 3 than in the other two groups. In predicting irreversible dysfunction, the persistence of systolic flow reversal up to 48 hours had a higher positive predictive value (100%) than the presence of systolic flow reversal on day 0 (67%, p < 0.04). The negative predictive value of systolic flow reversal at 48 hours (83%) was comparable in accuracy to the presence of systolic flow reversal on day 0 (85%, NS). Conclusions: In reperfused anterior acute myocardial infarction, serial assessment of coronary flow velocity in the left anterior descending coronary artery is feasible using transthoracic Doppler echocardiography, and the persistence of systolic flow reversal at 48 hours is a more specific marker of irreversible dysfunction than peak creatine kinase or diastolic deceleration time.
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