Three-year duration of benefit from abciximab in patient receiving stents for acute myocardial infarction in the randomized double-blind ADMIRAL study.

We would like to raise the following issues in response to thearticle reporting results of the ADMIRAL study by Montalescot     

Long-term mortality benefit with the combination of stents and abciximab for cardiogenic shock complicating acute myocardial infarction.

Cardiogenic shock secondary to ischemic heart disease is associated with a high mortality rate, and recent trials have established the benefit of an early invasive approach. However, the role of adjunctive abciximab and stenting for cardiogenic shock has not been established. We prospectively examined collected data from 96 consecutive patients who underwent emergent percutaneous coronary intervention for cardiogenic shock over the past 7 years. Patients were classified as receiving stent plus abciximab, stent alone, percutaneous transluminal coronary angiopplasty (PTCA) plus abciximab, or PTCA alone. Baseline characteristics of the 4 groups were similar. During 2.5 years of follow-up, the mortality rates for stent plus abciximab, stent only, PTCA plus abciximab, and PTCA alone were 33%, 43%, 61%, and 68%, respectively (log-rank p = 0.028). Achievement of postprocedural Thrombolysis In Myocardial Infarction 3 flow was higher with stent plus abciximab than with the other interventions (85% vs 65%, p = 0.048). By multivariate analysis, absence of stent use (hazard ratio 2.58, 95% confidence interval 1.36 to 4.90, p = 0.004) and left ventricular ejection function 相似文献   

Five-year outcome of patients with acute myocardial infarction enrolled in a randomised trial assessing the value of abciximab during coronary artery stenting

Aims The aim of the study was to investigate the long-term (fiveyears) efficacy of glycoprotein IIb/IIIa inhibition with abciximabgiven as an adjunct therapy to coronary stenting in patientswith acute myocardial infarction (MI) using the patient cohortof the Intracoronary Stenting and Antithrombotic Regimen-2 (ISAR-2)randomised trial. Methods and results The patient cohort of ISAR-2 trial (401patients)was followed up for 5 years after enrolment. There were 201patients in the abciximab group (stenting plus abciximab) and200 patients in the control group (stenting without abciximab).The primary end-point of the study was mortality at 5 years.Recurrent MI and target vessel re-vascularisation were alsoassessed at 5 years after enrolment. On the basis of the Kaplan–Meieranalyses, the 5-year mortality was 17.8% (35 patients) in thegroup with abciximab and 14.6% (29 patients) in the controlgroup (relative risk, 1.20 [95% confidence interval, 0.73–1.96];). The 5-year combined incidence of death, recurrent MI and target vessel re-vascularisation was 38.2%(76 patients) in the group of abciximab and 37.7% (75 patients)in the control group (relative risk, 0.97 [95% confidence interval,0.70–1.33]; ). Multivariable analysis showed no significant independent association of abciximab with5-year mortality (adjusted hazard ratio, 1.16 [95% confidenceinterval, 0.70–1.92]; ). Conclusion These findings are not in support of a sustainedclinical benefit at 5 years with the use of abciximab duringcoronary artery stenting in patients with acute MI.     

Aborted myocardial infarction in intracoronary compared with standard intravenous abciximab administration in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Backgound

Abciximab reduces major adverse cardiac events (MACEs) in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Intracoronary (IC) abciximab bolus application might be more effective than a standard intravenous (IV) bolus. So far the occurrence of aborted MI, a new therapeutic target of effective treatment in STEMI, has not been evaluated in IC versus IV abciximab administration in STEMI patients undergoing primary PCI.

Methods

To investigate the extent of aborted MI, 154 patients undergoing primary PCI were randomized to either IC (n = 77) or IV (n = 77) bolus abciximab administration with subsequent 12-hour intravenous infusion. For assessment of infarct size and extent of microvascular obstruction, all patients underwent late enhancement magnetic resonance imaging (MRI). Aborted MI was defined by major (≥ 50%) ST-segment resolution and a lack of subsequent cardiac enzyme rise ≥ 2 the upper normal limit. We also assessed the occurrence of true aborted MI defined as the absence of myocardial necrosis in MRI.

Results

The incidence of aborted MI was significantly higher in the IC group (p = 0.04); true aborted MI was only observed in the IC abciximab group (p = 0.01). At multivariable logistic regression analysis, IC abciximab application was a significant independent predictor of true aborted MI (p = 0.03). Aborted MI patients had an excellent prognosis at 6-month follow-up with no MACE as compared to 24 events in patients with non-aborted MI.

Conclusions

IC bolus application of abciximab in STEMI patients undergoing primary PCI results in a higher incidence of aborted MI and subsequent improved clinical outcome.     

国产瑞替普酶和尿激酶治疗急性心肌梗死疗效分析

目的 观察国产瑞替普酶和尿激酶治疗ST段抬高型急性心肌梗死的疗效.方法 回顾性分析106例STEMI患者的临床资料.根据溶栓药物不同将患者分为瑞替普酶治疗组53例,尿激酶治疗组53例,比较两组患者的再通率、心功能、出院存活率、住院天数、出血率,以及低血压、休克、恶性心律失常发生率和心脏骤停、心衰发生率的差别.结果 国产瑞替普酶组在再通率、心功能恢复、出院存活率、住院天数、出血率及低血压、休克、恶性心律失常发生率,心脏骤停发生率和心衰发生率方面与尿激酶组比较差异有统计学意义（P＜0.05）.结论 国产瑞替普酶较尿激酶对急性ST段抬高型心肌梗死有良好的疗效.     

Short- and long-term clinical benefit of sirolimus-eluting stents compared to conventional bare stents for patients with acute myocardial infarction

OBJECTIVES: This study investigated the clinical outcomes of patients with ST-segment elevation myocardial infarction (MI) treated with sirolimus-eluting stents (SESs) or with conventional bare stents. BACKGROUND: The clinical impact of SES implantation for patients with ST-segment elevation MI is currently unknown. METHODS: Primary angioplasty was performed with SESs in 186 consecutive patients with acute MI who were compared with 183 patients treated with bare stents. The incidence of death, reinfarction, and repeat revascularization was assessed at 30 and 300 days. RESULTS: Postprocedure vessel patency, enzymatic release, and the incidence of short-term adverse events were similar in both the sirolimus and the bare stents (30-day rate of death, reinfarction, or repeat revascularization: 7.5% vs. 10.4%, respectively; p = 0.4). Stent thrombosis was not diagnosed in any patient in the sirolimus group and occurred in 1.6% of patients treated with bare stents (p = 0.1). At 300 days, treatment with SESs significantly reduced the incidence of combined adverse events (9.4% vs. 17%; hazard ratio [HR] 0.52 [95% confidence interval (CI) 0.30 to 0.92]; p = 0.02), mainly due to a marked reduction in the risk of repeat intervention (1.1% vs. 8.2%; HR 0.21 [95% CI 0.06 to 0.74]; p = 0.01). CONCLUSIONS: Compared to conventional bare stents, the SESs were not associated with an increased risk of stent thrombosis and were effective in reducing the incidence of adverse events at 300 days in unselected patients with ST-segment elevation acute MI referred for primary angioplasty.     

Thrombin generation and fibrinolytic activities among patients receiving reduced-dose alteplase plus abciximab or undergoing direct angioplasty plus abciximab for acute myocardial infarction

The purpose of this study was to determine the impact of these 2 reperfusion strategies (reduced-dose alteplase plus abciximab or direct angioplasty plus abciximab) on fibrinolytic and thrombin generation activities. The effect of reduced-dose alteplase plus abciximab and direct angioplasty plus abciximab on hemostatic factors is unknown. Of 70 patients with acute myocardial infarction of < or = 6 hours, 34 were randomized to reduced-dose alteplase (35 to 50 mg in 1 hour) and 36 to direct angioplasty. A standard bolus and infusion dose of abciximab was administered to all patients. Blood specimens were collected at baseline, and at 1, 4, 12, and 24 hours. The following parameters were assayed: fibrinogen, plasminogen and antiplasmin activities, tissue plasminogen activator antigen, D-dimer, prothrombin fragments F1 + 2, and thrombin/antithrombin III complexes. Among patients treated with reduced-dose alteplase plus abciximab, the fibrinogen level decreased by 28.4% in the first hour (11.7 +/- 3.4 vs 7.8 +/- 2.5 micromol/L, p <0.001). Correspondingly, plasminogen and antiplasmin activities decreased by 43.8% (p <0.001) and 59.1% (p <0.001), respectively. Prothrombin fragments F1 + 2 increased from 2.2 +/- 1.7 to 4.2 +/- 1.6 nmol/L (1 hour) (p <0.001) and thrombin/antithrombin III increased from 16.3 +/- 15.0 to 33.5 +/- 19.9 microg/L (1 hour) (p <0.001). Conversely, in the direct angioplasty group, there was a marginal elevation in fibrinogen level at 1 hour (10.2 +/- 2.4 vs 10.6 +/- 2.0 micromol/L, p = 0.064) despite a significant reduction in plasminogen and an increase in tissue plasminogen activator levels. There was no significant change in prothrombin fragments F1 + 2 and thrombin/antithrombin III levels. Thus, there was considerable fibrinolytic activity with reduced-dose alteplase plus abciximab; thrombin generation was not prevented. Among patients treated with direct angioplasty, there was some endogenous fibrinolytic activity, but there was no significant thrombin generation.     

Effects on mortality of abciximab in ST-elevation myocardial infarction treated with percutaneous coronary intervention including stent implantation

OBJECTIVES: To investigate the effects of abciximab on mortality in ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) including stent implantation. DESIGN: Meta-analysis of three selected randomized studies and analysis of data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). SUBJECTS: Pooled data from randomized studies containing in total 1,736 patients undergoing PCI with stent implantation because of STEMI with duration between symptom and treatment <12 h, and 7,436 patients from SCAAR treated with PCI because of STEMI (52% treated with abciximab) in Sweden 2000-2004. RESULTS: Analyses of pooled data showed that abciximab was associated with a decreased risk of reinfarction [odds ratio (OR) 0.38] and urgent target vessel revascularization (OR 0.38) at 30 days. No effect was seen on mortality at 30 days or 6 months. Multivariate analysis of data from SCAAR showed that abciximab reduced the risk of death during 14 months of follow-up (hazard ratio 0.82). CONCLUSIONS: The results are encouraging and support the ACC/AHA and ESC recommendation to use abciximab in treatment of STEMI with PCI including stent implantation. Considering that the pooled results from previous trials showed no effect of abciximab on mortality and the registry part of the present study was observational, the results encourage carrying out new randomized studies of abciximab in STEMI treated with PCI, including stent implantation, with sufficient size and length of follow-up.     

Prediction of mortality in hospital survivors of STEMI: External validation of a novel acute myocardial infarction prognostic score

Introduction & objective

Recently we developed and internally-validated the Soroka Acute Myocardial Infarction (SAMI) Score for prediction of all-cause long-term mortality (c-statistic 0.83–0.94) among hospital-survivors of AMI. We aimed to perform an external-validation of the SAMI score for long-term risk-stratification of STEMI patients undergoing PCI.

Meta-analysis of randomized trials on drug-eluting stents vs. bare-metal stents in patients with acute myocardial infarction.

AIMS: To compare the efficacy and safety of drug-eluting stents vs. bare-metal stents in patients with acute ST-segment elevation myocardial infarction. METHODS AND RESULTS: We performed a meta-analysis of eight randomized trials comparing drug-eluting stents (sirolimus-eluting or paclitaxel-eluting stents) with bare-metal stents in 2786 patients with acute ST-segment elevation myocardial infarction. All patients were followed up for a mean of 12.0-24.2 months. Individual data were available for seven trials with 2476 patients. The primary efficacy endpoint was the need for reintervention (target lesion revascularization). The primary safety endpoint was stent thrombosis. Other outcomes of interest were death and recurrent myocardial infarction. Drug-eluting stents significantly reduced the risk of reintervention, hazard ratio of 0.38 (95% CI, 0.29-0.50), P < 0.001. The overall risk of stent thrombosis: hazard ratio of 0.80 (95% CI, 0.46-1.39), P = 0.43; death: hazard ratio of 0.76 (95% CI, 0.53-1.10), P = 0.14; and recurrent myocardial infarction: hazard ratio of 0.72 (95% CI, 0.48-1.08, P = 0.11) was not significantly different for patients receiving drug-eluting stents vs. bare-metal stents. CONCLUSION: The use of drug-eluting stents in patients with acute ST-segment elevation myocardial infarction is safe and improves clinical outcomes by reducing the risk of reintervention compared with bare-metal stents.     

Effect of abciximab on prothrombin activation and thrombin generation in patients with acute myocardial infarction also receiving reteplase

Fibrinolysis in acute myocardial infarction activates blood coagulation and may favor reocclusion or ischemic complications. The aim of the GUSTO V Italian Hematologic Substudy was to compare the effects of full-dose reteplase on coagulation activation markers with those of half-dose reteplase combined with full-dose abciximab, a platelet glycoprotein IIb/IIIa receptor antagonist, during the early phase after acute myocardial infarction.     

Role of aldosterone in mid- and long-term left ventricular remodelling after acute myocardial infarction: The REMI study

Aims

Whether aldosterone levels after myocardial infarction (MI) are associated with mid- and long-term left ventricular (LV) remodelling in the era of systematic use of renin–angiotensin system inhibitors is uncertain. We prospectively investigated the relationship between aldosterone levels and mid- and long-term LV remodelling in patients with acute MI.

Methods and results

Plasma aldosterone was measured in 119 patients successfully treated by primary percutaneous coronary angioplasty for a first acute ST-elevation MI (STEMI) 2–4 days after the acute event. LV volumes were assessed by cardiac magnetic resonance (CMR) and transthoracic echocardiography (TTE) in the same timeframe and 6 months later. LV assessment was repeated by TTE 3–9 years after MI (n = 80). The median aldosterone level at baseline was 23.1 [16.8; 33.1] pg/ml. In the multivariable model, higher post-MI aldosterone concentration was significantly associated with more pronounced increase in LV end-diastolic volume index (TTE: β ± standard error [SE]: 0.113 ± 0.046, p = 0.015; CMR: β ± SE: 0.098 ± 0.040, p = 0.015) and LV end-systolic volume index (TTE: β ± SE: 0.083 ± 0.030, p = 0.008; CMR: β ± SE: 0.064 ± 0.032, p = 0.048) at 6-month follow-up, regardless of the method of assessment. This result was consistent also in patients with a LV ejection fraction (LVEF) >40%. The association between baseline plasma aldosterone and adverse LV remodelling did not persist at the 3–9-year follow-up evaluation.

Conclusion

Aldosterone concentration in the acute phase was associated with adverse LV remodelling in the medium term, even in the subgroup of patients with LVEF >40%, suggesting a potential role of the mineralocorticoid system in post-MI adverse remodelling. Plasma aldosterone was no longer associated with LV remodelling in the long term (NCT01109225).     

国产瑞替普酶和进口阿替普酶对ST段抬高型心肌梗死的溶栓疗效比较

目的 比较国产瑞替普酶和进口阿替普酶对急性ST段抬高型心肌梗死（STEMI）的溶栓效果.方法 回顾性分析100例STEMI患者,根据溶栓药物不同分为国产瑞替普酶治疗组52例,进口阿替普酶治疗组48例,比较两组患者再通率、心功能、出院存活率、住院天数、出血率、低血压、休克、恶性心律失常发生率、心脏骤停、心衰发生率的差别.结果 两组在再通率、心功能恢复、出院存活率、住院天数、出血率、低血压、休克、恶性心律失常发生率、心脏骤停发生率、心衰发生率方面差异无统计学意义（P＞0.05）.结论 国产瑞替普酶和进口阿替普酶治疗STEMI均有良好的疗效,但国产瑞替普酶使用简便、易操作,更适合在临床使用.     

雷帕霉素洗脱支架在急性心肌梗死紧急介入治疗中的应用

目的:探讨雷帕霉素洗脱支架（cypherTM）在急性心肌梗死（AMI）紧急介入治疗中应用的安全性及有效性。方法:回顾分析我科行紧急介入治疗并置入cypherTM支架的58例AMI患者（其中ST段抬高性AMI41例,非ST段抬高性AMI17例）的即刻疗效和随访结果。结果:58例患者紧急介入治疗均获得成功,58支梗死相关血管的罪犯病变共置入65枚cypherTM支架。住院期间未发生有关的严重并发症。3～12（7±4）月随访期内,2例患者因再次胸痛入院,其中1例经造影证实为其他冠脉分支新病变,1例为普通支架内再狭窄,行再次介入治疗。其余患者随访期内未出现心脏事件。58例患者共有11例复查了冠脉造影,CypherTM支架内均无再狭窄。结论:cypherTM支架在AMI的紧急介入治疗中安全有效。