A randomized study of prourokinase during primary percutaneous coronary intervention in acute ST‐segment elevation myocardial infarction

Objectives

To evaluate the efficacy and safety of intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions (PCI) in patients with acute ST‐segment elevation myocardial infarction (STEMI).

Methods

Acute STEMI patients underwent primary PCI were randomly divided into two groups: intracoronary prourokinase (IP) group (n = 118) and control group (n = 112). During primary PCI, prourokinase or saline were injected to the distal end of the culprit lesion via balloon catheter after balloon catheter dilatation. Demographic and clinical characteristics, infarct size, myocardial reperfusion, and cardiac functions were evaluated and compared between two groups. Hemorrhagic complications and MACE occurred in the 6‐months follow up were recorded.

Results

No significant differences were observed between two groups with respect to baseline demographic, clinical, and angiographic characteristics (P > 0.05). In IP group, more patients had complete ST segment resolution (>70%) compared with control group (P < 0.05). Patients in IP group showed lower levels of serum CK, CK‐MB and TnI, and a much higher myocardial blood flow (MBF) than those in control group (P < 0.05). No significant differences of TIMI major or minor bleeding complications were observed between the two groups (P > 0.05). At 6‐months follow‐up, there was a trend that patients in the IP group had a less chance to have MACE, though it was not statistically different (8.5% vs 12.5%, P > 0.05).

Conclusions

Intracoronary administration of prourokinase via balloon catheter during primary PCI effectively improved myocardial perfusion in STEMI patients.     

Impact of limited English proficiency on presentation and outcomes of patients undergoing primary percutaneous coronary intervention for ST‐elevation myocardial infarction

Doctor–patient language discordance has been shown to lead to worse clinical outcomes. In this study of patients undergoing primary percutaneous coronary intervention for ST‐elevation myocardial infarction at an Australian health service, we demonstrated that limited English proficiency (LEP) is an independent predictor of prolonged symptom‐to‐door time, but does not lead to worse 30‐day mortality compared with English‐proficient patients. More effort needs to be placed in providing public health education in varied languages to encourage early presentation to hospital for patients with LEP.     

急诊经桡动脉与股动脉入路介入治疗ST段抬高急性心肌梗死对比研究

目的观察经桡动脉入路行急诊ST段抬高急性心肌梗死直接经皮冠状动脉介入(PCI)治疗的有效性和安全性。方法选择沈阳军区总医院2005年1月至2006年10月连续607例ST段抬高性急性心肌梗死(STEMI)住院患者,分别接受经桡动脉入路(273例)或经股动脉入路(334例)途径行PCI治疗,观察两组手术成功率和并发症发生率。结果两组患者PCI成功率差异无统计学意义(97.07%对95.81%,P>0.05)。经桡动脉入路组局部血肿、假性动脉瘤、迷走反射发生率显著低于经股动脉入路组。结论行PCI治疗的STEMI患者经桡动脉入路途径是安全、有效和可行的方法,与经股动脉比较,经桡动脉途径可减少并发症的发生。     

优化急性ST段抬高型心肌梗死的直接经皮冠状动脉介入治疗

对ST段抬高型心肌梗死实施直接经皮冠状动脉介入治疗不应只是为获得TIMI 3级血流,而应是良好的心肌灌注。可通过上游使用血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂、他汀类调脂药,个体化正确使用血栓抽吸装置,必要时延迟支架植入等手段,优化直接经皮冠状动脉介入治疗术的效果。     

急性ST段抬高性心肌梗死直接经皮穿刺冠状动脉成形术后早期ST段变化的意义

目的探讨急性ST段抬高性心肌梗死(STEMI)直接经皮穿刺冠状动脉成形术(PCI)术后梗死相关动脉(IRA)完全开通、前向血流恢复后,早期ST段变化的临床意义。方法回顾性分析2001-01~12北京朝阳医院心脏中心收治的216例直接PCI后、IRA完全开通、前向血流恢复正常病人的临床、冠脉造影和心电图资料。直接PCI术后,ST段抬高指数≥50%的病人41例,为病例组。从其余175例ST段抬高指数<50%的病人中随机抽取50例,为对照组。结果两组病人的ST段抬高指数、Q波计数、室壁运动积分和平均肌酸激酶值差异有显著性意义(P<0·05);术后2周,ST段早期恢复较ST段持续抬高病人的室壁运动改善,左室射血分数(LVEF)、心排指数(CI)、每搏指数(SVI)增加(P<0·05)。ST段早期恢复合并心功能不全的病人,术后2周室壁运动增强,LVEF、CI、SVI增加(P<0·05),左室舒张末容积、左室收缩末容积减少(P<0·01)。结论STEMI直接PCI后IRA完全开通、前向血流恢复正常而ST段持续抬高病人的梗死范围扩大,左室舒缩功能不全严重,可能与心肌组织没有有效地恢复血流灌注或无复流有关。     

A randomized comparison of manual versus mechanical thrombus removal in primary percutaneous coronary intervention in the treatment of ST‐segment elevation myocardial infarction (TREAT‐MI)

Objectives : The objective of this study was to compare the efficacy and long‐term clinical outcome of manual thrombus aspiration with the Export catheter (Medtronic, Minneapolis, MN) versus mechanical thrombus cutting/aspiration with the X‐sizer system (eV3, White Bear Lake, MN) in primary percutaneous coronary intervention (PPCI). Background : In PPCI for acute ST‐segment elevation myocardial infarction (STEMI), markers of myocardial reperfusion are improved with adjunctive thrombectomy. Previous studies of different devices showed a variability in performance, suitability, and short‐term clinical outcome. In current literature, no direct comparison is available. Methods : We prospectively randomized 201 patients admitted for PPCI for STEMI to either the Export catheter or the X‐sizer prior to stent deployment. Technical success in advancing to and across the lesion, improvement of flow, reduction of thrombus, and the effect on ST‐segment resolution were examined. The primary endpoint of the follow‐up study was the combined endpoint of cardiac death, recurrent myocardial infarction (MI), or target‐vessel revascularization (TVR) at 3 years. Results : Although the Export catheter was more successfully deployed, other procedural parameters were similar with a trend toward better ST‐segment resolution (56.6% vs. 44%; P = 0.06) as compared to the X‐sizer system. The occurrence of the primary clinical endpoint at 3 years was 22.2% and 18.6%, respectively (HR 1.20; 95% CI 0.65–2.22; P = 0.35). Conclusion : Despite shorter procedural times, better lesion crossing, and fewer complications, both surrogate endpoints as well as 3‐year clinical follow‐up were similar with the use of the Export catheter as compared to the X‐sizer system. © 2011 Wiley‐Liss, Inc.     

替格瑞洛用于老年急性ST段抬高型心肌梗死急诊PCI治疗患者的临床研究

目的评估替格瑞洛用于急性ST段抬高型心肌梗死(STEMI)急诊经皮冠状动脉介入治疗(PCI)患者的临床疗效。方法回顾性分析2012年11月至2014年12月北京潞河医院心血管内科急性STEMI接受急诊PCI手术患者240例,分成替格瑞洛(n=94)和氯吡格雷(n=146)两组,比较两组患者急诊PCI术后心肌梗死溶栓治疗(TIMI)3级血流、术后心电图ST段回落(STR)情况、出血学术研究联合会(BARC)定义的出血发生率、呼吸困难发生率、服药情况及停换药原因、院内和术后12个月主要心脏不良事件(MACE)发生率等指标。结果与氯吡格雷组相比,替格瑞洛能提高PCI术后TIMI 3级血流的患者比例(90.5%vs80.8%,P=0.024.)。12个月内两组BARC出血分级、呼吸困难发生率差异无统计学意义(28.7%vs24.0%,P=0.412;12.8%vs6.8%,P=0.121)。替格瑞洛组和氯吡格雷组12个月内停药或更改抗栓方案差异有统计学意义(P0.001),主要原因是医师更改抗栓方案、经济原因和呼吸困难(50.0%傩1.4%,P0.001;12.8%vs 1.4%,P0.001;5.3%vs 0.7%,P=0.025)。两组院内、12个月MACE差异无统计学意义(5.3%vs 5.5%,P=0.957;8.5%vs 8.9%,P=0.916)。结论替格瑞洛用于老年STEMI患者急诊PCI可改善术后血流,且不增加出血发生率,停换药的原因是医师更改抗栓方案、经济原因和呼吸困难。     

A survey of primary percutaneous coronary intervention for patients with ST segment elevation myocardial infarction in Canadian hospitals

BACKGROUND:

Historically, access to primary percutaneous coronary intervention (PCI) for the treatment of patients with ST segment elevation myocardial infarction (STEMI) has been limited in Canada. Recent studies have identified innovative strategies to improve timely access and reduce reperfusion time. Accordingly, the contemporary use of primary PCI treatment in Canada was ascertained.

METHODS:

A cross-sectional survey of all 38 Canadian hospitals that were capable of performing PCI procedures was conducted from June 2007 to November 2007. The survey focused on the practice of primary PCI for patients with STEMI and whether the hospitals had implemented internal strategies to reduce ‘door-to-balloon’ times. Analyses were performed at the level of geographical regions.

RESULTS:

Overall, 71% of PCI hospitals (27 of 38) provided around-the-clock primary PCI for patients with STEMI, but the proportion of PCI hospitals offering this service varied widely, from 33% to 100% across regions. All Canadian PCI hospitals provided around-the-clock rescue PCI treatment to STEMI patients who had failed fibrinolytic therapy. In terms of strategies that are associated with reduced reperfusion time, it was observed that only 42% of PCI hospitals (16 of 38) provided feedback on door-to-balloon time to the emergency department and to the cardiac catheterization laboratories within one week of the primary PCI procedure. Overall, 24% of the hospitals had not adopted any of the four identified strategies to improve door-to-balloon time.

CONCLUSION:

Although the majority of Canadian hospitals with PCI capability provide around-the-clock primary PCI for patients with STEMI, significant variations in this practice exist across the country. Canadian PCI hospitals have not consistently adopted strategies that are associated with improved door-to-balloon time.     

Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

Acute coronary syndromes presenting with ST elevation are usually treated with emergency reperfusion/revascularisation therapy. In contrast current evidence and national guidelines recommend risk stratification for non ST segment elevation myocardial infarction(NSTEMI) with the decision on revascularisation dependent on perceived clinical risk. Risk stratification for STEMI has no recommendation. Statistical risk scoring techniques in NSTEMI have been demonstrated to improve outcomes however their uptake has been poor perhaps due to questions over their discrimination and concern for application to individuals who may not have been adequately represented in clinical trials. STEMI is perceived to carry sufficient risk to warrant emergency coronary intervention [by primary percutaneous coronary intervention(PPCI)] even if this results in a delay to reperfusion with immediate thrombolysis. Immediate thrombolysis may be as effective in patients presenting early, or at low risk, but physicians are poor at assessing clinical and procedural risks and currently are not required to consider this. Inadequate data on risk stratification in STEMI inhibits the option of immediate fibrinolysis, which may be cost-effective. Currently the mode of reperfusion for STEMI defaults to emergency angiography and percutaneous coronary intervention ignoring alternative strategies. This review article examines the current risk scores and evidence base for risk stratification for STEMI patients. The requirements for an ideal STEMI risk score are discussed.     

Comparison of procedural times,success rates,and safety between left versus right radial arterial access in primary percutaneous coronary intervention for acute ST‐segment elevation myocardial infarction

Objective: To evaluate if there are differences in procedural times, success rates, and safety between left and right radial approach (LRA and RRA, respectively) in primary percutaneous coronary intervention (PCI) for ST‐elevation myocardial infarction (STEMI). Background: Given conflicting reports of different procedural success with LRA vs. RRA, it is unclear if the side of radial access impacts in‐room procedural times and success rates in primary PCI. At our institution the LRA has been commonly used in certain STEMI patients. Our clinical database was reviewed to see if routine use of the LRA could generate favorable technical success and reperfusion times as compared to the RRA. Methods: We retrospectively analyzed 135 consecutive STEMI patients treated with primary PCI performed via the left and right radial approach at our institution. Results: There were 50 cases in the LRA group and 85 in the RRA group. There was no difference in median procedural times including total procedure time (LRA 53.5 mins vs. RRA 52 mins, P = 0.95), room‐to‐cannulation (LRA 12 min vs. RRA 13 min, P = 0.40) or room‐to‐balloon times (LRA 30 min vs. RRA 31 min, P = 0.74). There were no significant differences in procedural success rates (LRA 100% vs. RRA 97.6%, P = 0.27), or procedure‐related complications or death between the two groups. Conclusions: Left and right trans‐radial approach for primary PCI have similar in room procedural times, success rates, and comparable safety. Trans‐radial PCI through either arm is a feasible and safe approach in patients with STEMI. © 2010 Wiley‐Liss, Inc.