Abciximab and early adjunctive percutaneous coronary intervention are associated with improved ST-segment resolution after thrombolysis: Observations from the TIMI 14 Trial

BACKGROUND: Percutaneous coronary intervention (PCI) improves clinical outcomes in selected patients with failed thrombolysis but has not been proven to benefit patients who achieve a patent infarct-related artery. Even after successful epicardial reperfusion, myocardial perfusion may be inadequate. We sought to evaluate whether a strategy that uses a reperfusion regimen containing abciximab and a reduced-dose thrombolytic agent (combination therapy), followed by early adjunctive PCI, would result in improved myocardial perfusion, as assessed by ST-segment resolution. METHODS: ST resolution from 90 to 180 minutes after therapy was calculated for all 410 patients from the TIMI 14 trial who had evaluable electrocardiograms at both time points and who were treated with alteplase or reteplase. Patients were grouped according to whether they were treated with combination therapy or full-dose thrombolytic agent alone and whether they underwent PCI between the 90- and 180-minute electrocardiographic measurements. RESULTS: Among 105 patients who underwent adjunctive PCI between 90 and 180 minutes, mean ST resolution from 90 to 180 minutes was significantly greater in those who had received combination therapy versus those who had received full-dose thrombolytic alone (54% vs 8%; P =.002). Among 241 patients with TIMI grade 3 flow in the infarct-related artery at 90 minutes, adjunctive PCI significantly improved mean ST resolution in patients who had been treated with combination therapy (57% [PCI] vs 24% [no PCI]; P =.006), but PCI did not have this effect in patients who had received thrombolytic therapy alone (1% [PCI] vs 10% [no PCI]; P =.70). In a multivariate model controlling for factors that would be expected to independently influence 90- to 180-minute ST resolution, abciximab treatment remained significantly associated with greater ST resolution (P =.008). CONCLUSIONS: A strategy that uses a combination reperfusion regimen that includes abciximab, followed by early adjunctive PCI, is associated with greater ST-segment resolution, which may reflect enhanced tissue level and microvascular perfusion. Future studies should evaluate prospectively the clinical efficacy of this strategy.     

Primary versus rescue percutaneous coronary intervention in patients with acute myocardial infarction

OBJECTIVE: To compare angiographic and clinical outcomes of patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI) versus rescue PCI following failed thrombolysis. BACKGROUND: Patients presenting with AMI are treated either with primary PCI or with thrombolysis. When thrombolysis fails, rescue PCI is performed. METHODS AND RESULTS: We compared the outcome of 105 consecutive patients with AMI who underwent either primary PCI (60 patients) or rescue PCI (45 patients) between January 1997 and January 1999. The patients were followed for up to 6 months. Time delay to reperfusion was significantly longer in the rescue PCI group (354 vs. 189 min; p < 0.001). The majority of patients received a stent (93%). Glycoprotein (GP) IIb/IIIa inhibitors were used in 53% of patients in the primary PCI group and in 22% in the rescue group. TIMI grade 3 flow was achieved in 93.3% of patients in the primary PCI group and in 88.8% in the rescue group (p = 0.08). Post-procedure ejection fraction was 53% in the primary PCI group and 47% in the rescue group (p = 0.014). A composite endpoint of death, recurrent MI, repeat PCI, coronary artery bypass grafting (CABG) and recurrent angina at 6 months occurred in 35% of the patients in the primary PCI group and 26.7% in the rescue group (p = 0.36). CONCLUSION: Despite a significant delay to reperfusion and a lower immediate post-procedure ejection fraction, the clinical outcome of patients treated with rescue PCI following failed thrombolysis appears to be similar to that of patients treated with primary PCI at 6 months.     

Facilitation of early percutaneous coronary intervention after reteplase with or without abciximab in acute myocardial infarction: results from the SPEED (GUSTO-4 Pilot) Trial.

OBJECTIVES: We examined the utility of early percutaneous coronary intervention (PCI) in a trial that encouraged its use after thrombolysis and glycoprotein IIb/IIIa inhibition for acute myocardial infarction (MI). BACKGROUND: Early PCI has shown no benefit when performed early after thrombolysis alone. METHODS: We studied 323 patients (61%) who underwent PCI with planned initial angiography, at a median 63 min after reperfusion therapy began. A blinded core laboratory reviewed cineangiograms. Ischemic events, bleeding, angiographic results, and clinical outcomes were compared between early PCI and no-PCI patients (n = 162), between patients with Thrombolysis in Myocardial Infarction (TIMI) flow grade 0 or 1 before PCI versus flow grade 2 or 3, and among three treatment regimens. RESULTS: Early PCI patients showed a procedural success (<50% residual stenosis and TIMI flow grade 3) rate of 88% and a 30-day composite incidence of death, reinfarction, or urgent revascularization of 5.6%. These patients had fewer ischemic events and bleeding complications (15%) than did patients not undergoing early PCI (30%, p = 0.001). Early PCI was used more often in patients with initial TIMI flow grade 0 or 1 versus flow grade 2 or 3 (83% vs. 60%, p < 0.0001). Patients receiving abciximab with reduced-dose reteplase (5 U double bolus) showed an 86% incidence of TIMI grade 3 flow at approximately 90 min and a trend toward improved outcomes. CONCLUSIONS: In this analysis, early PCI facilitated by a combination of abciximab and reduced-dose reteplase was safe and effective. This approach has several advantages for acute MI patients, which should be confirmed in a dedicated, randomized trial.     

Pharmacoinvasive therapy for ST elevation myocardial infarction in China: a pilot study

Most patients with acute ST-elevation myocardial infarction (STEMI) cannot receive timely primary percutaneous coronary intervention (PCI) because of lack of facilities or delays in patient transfer or catheterization team mobilization. In these patients, early routine post-thrombolysis PCI might be a reasonable, useful strategy. This study investigated feasibility and safety of early PCI after successful half-dose alteplase reperfusion in a Chinese population. Patients with STEMI received half-dose alteplase if expected time delay to PCI was ≥90?min. Patients who reached clinical criteria of successful thrombolysis reperfusion were recommended to undergo diagnostic angiography within 3-24?h after thrombolysis. Patients with residual stenosis ≥70% in the infarct-related artery underwent PCI, regardless of flow or patency status. Epicardial arterial flow was assessed using thrombolysis in myocardial infarction (TIMI) flow grade and TIMI frame count (CTFC). Myocardial perfusion was assessed using myocardial blush grade (MBG) and TIMI myocardial perfusion frame count (TMPFC). Forty-nine patients were enrolled and underwent diagnostic angiography 3-11.3?h (median 6.5?h) after thrombolysis. Forty-six patients underwent PCI. No procedure-related complications occurred, except two patients who had no reflow after PCI. Twenty-two (47.8%) patients had TIMI grade 3 flow before PCI and 33 (71.7%) after PCI. CTFC was significantly improved after PCI (48.5?±?32.1 vs. 37.9?±?25.6, P?=?0.01). MBG and TMPFC exhibited a similar improving trend after PCI, and the best myocardial perfusion tended to be achieved 3-12?h after lysis. During the 30-day follow-up, there were two deaths. The composite end point of death, cardiogenic shock, heart failure, reinfarction, and recurrent ischemia occurred in four patients. TIMI minor bleeding occurred in four patients. No TIMI major bleeding and stroke occurred. Early routine PCI after half-dose alteplase thrombolysis in Chinese population appears feasible. A larger clinical trial should be designed to further elucidate its efficacy and safety. Early PCI after thrombolysis in STEMI: The EARLY-PCI pilot feasibility study, ChiCTR-TNC-11001363.     

The level I cardiovascular center: is it time?

There is no uniform approach to treating the 1.5 million US citizens who have an acute myocardial infarction (AMI) each year. This contrasts with the trauma system developed to efficiently triage and treat the critically injured accident victim. Only two thirds of patients with ST-segment elevation AMI in the United States are treated with thrombolytic therapy or primary angioplasty (percutaneous coronary intervention [PCI]) which can reduce the 30-day mortality rate from approximately 15% to 6%-10%. The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial demonstrated that AMI patients who received prehospital thrombolytic therapy and were brought to the nearest receiving hospital experienced a 32-minute reduction in the time to treatment and time to ST-elevation resolution compared with those treated at their time of hospital arrival. This expedited therapy was associated with a low in hospital mortality rate (4.7%). The potential benefit of facilitated PCI with partial-dose thrombolysis and abciximab administration was demonstrated by the Strategies for Patency Enhancement in the Emergency Department (SPEED) investigators who found that double bolus recombinant plasminogen activator (reteplase) (5 + 5 megaunits) and abciximab with the addition of early PCI, resulted in a final infarct-related artery TIMI 3 flow rate of 86% compared with 77% with combination therapy alone. The Primary Angioplasty in Acute Myocardial Infarction (PAMI) investigators have shown that patients admitted with infarct-related artery TIMI 3 flow at the time of primary PCI had less than a 1% 6-month mortality. Treating AMI patients with prehospital, partial dose thrombolysis followed by immediate transport to a Level I cardiovascular center (bypassing the closest hospital if necessary) for facilitated infarct-related artery PCI has the potential to reduce the mortality in ST-elevation AMI patients from 6%-10% to less than 4% which could translate into saving approximately 500 lives per day in the United States. It is time to validate this strategy with a randomized clinical trial, the Prehospital Administration of Thrombolytic Therapy With Urgent Culprit Artery Revascularization trial (PATCAR).     

Reperfusion arrhythmias: are they only a marker of epicardial reperfusion or continuing myocardial ischemia after acute myocardial infarction?

Reperfusion arrhythmias are associated with epicardial reperfusion but may also be a sign of vascular reperfusion injury which can be seen as no-reflow phenomenon on coronary angiography and predicts in-hospital complications and recovery of left ventricular (LV) function. No-reflow phenomenon (thrombolysis in myocardial infarction [TIMI] 相似文献   

Angiographic and clinical outcomes in elderly subjects treated with percutaneous coronary intervention following fibrinolytic administration for ST-elevation myocardial infarction

Background Prior studies have demonstrated that the achievement of faster coronary artery flow following reperfusion therapies is associated with improved outcomes among ST-elevation myocardial infarction (STEMI) patients. The association of patient age with angiographic characteristics of flow and perfusion after rescue/adjunctive percutaneous coronary intervention (PCI) following the administration of fibrinolytic therapy has not been previously investigated. Objectives and Methods We examined the association between age (≥70 years or < 70years) and clinical and angiographic outcomes in 1472 STEMI patients who underwent rescue/adjunctive PCI following fibrinolytic therapy in 7 TIMI trials. We hypothesized that elderly patients would have slower post-PCI epicardial flow and worsened outcomes compared to younger patients. Results The 218 patients aged≥70 years (14.8%) had more comorbidities than younger patients. Although these patients had significant angiographic improvement in TTMI frame counts and rates of TIMI Grade 3 flow following rescue/adjunctive PCI, elderly patients had higher (slower) post-PCI TTMI frame counts compared to the younger cohort (25 vs 22 frames, P = 0.039) , and less often achieved post-PCI TTMI Grade 3 flow (80.1 vs 86.4% , P = 0.017). The association between age (≥70 years) and slower post-PCI flow was independent of gender, time to treatment, left anterior descending (LAD) lesion location, and pulse and blood pressure on admission. Elderly patients also had 4-fold higher mortality at 30 days (12.0 vs 2.7% , P = 0. 001). Conclusions This study suggests one possible mechanism underlying worsened outcomes among elderly STEMI patients insofar as advanced chronological age was associated with higher TTMI frame counts and less frequent TIMI Grade 3 flow after rescue/adjunctive PCI. (J Geriatr Gardiol 2005;2(1) :10-14)     

Long-term clinical outcomes after rescue angioplasty are not different from those of successful thrombolysis for acute myocardial infarction.

AIMS: The long-term value of rescue percutaneous transluminal coronary angioplasty (PTCA) in patients with ST-segment elevation myocardial infarction who received thrombolytic therapy but failed to achieve early recanalization of the artery is still debated. This study aimed to compare long-term outcomes after successful thrombolysis vs. systematic attempted rescue PTCA. METHODS AND RESULTS: A total of 362 consecutive patients with STEMI hospitalized within 6 h of symptom onset and treated with intravenous thrombolytic therapy were studied. Of these, 345 underwent coronary angiography within 90 min. Sixty per cent of patients achieved TIMI 3 flow and were treated medically; the in-hospital death rate in this group was 4%. Nine per cent of patients had TIMI 2 flow and 31% TIMI 0-1 flow. In this latter group, rescue PTCA was attempted in 85.8% with a hospital death rate of 5.5% (20% with failed vs. 4% with successful rescue PTCA, P=0.03). Eight year actuarial survival without recurrent myocardial infarction was no different in patients who had successful thrombolytic therapy and in patients with attempted rescue PTCA [78 and 95% CI (71-85) vs. 78 and 95% CI (68-87), respectively, hazard ratio: 0.93 (0.52-1.65), P=0.80]. Total mortality, cardiac mortality, and other composite endpoints also did not differ between groups. CONCLUSION: Routine attempted rescue PTCA 90 min after thrombolytic therapy in patients with persistent occlusion of the infarct-related vessels achieves long-term clinical outcomes which do not differ from those obtained by successful thrombolysis.     

Angiographic and clinical characteristics associated with the development of Q-wave and non-Q-wave myocardial infarction in the thrombolysis in myocardial infarction (TIMI) 14 trial

Background

In the absence of thrombolytic therapy, patients with non-Q-wave myocardial infarction (MI) have previously been shown to have lower long-term mortality rates than patients with Q-wave MI. The goal of our study was to examine the angiographic and clinical differences between non-Q-wave MI and Q-wave MI in patients with ST elevation MI (STEMI) in the era of thrombolytic and combination therapy of thrombolytics plus glycoprotein IIb/IIIa inhibitors.

Methods

Angiography was performed 90 minutes after thrombolytic administration in the Thrombolysis in Myocardial Infarction (TIMI) 14 trial. The development of a non-Q-wave MI was assessed on electrocardiogram performed at the time of hospital discharge. Angiographic findings were assessed at an angiographic core laboratory by blinded investigators.

Results

The qualifying episode of ST elevation developed into a non-Q-wave MI in 36% of patients (315/878) and into a Q-wave MI in 64% of patients (563/878). In patients in whom non-Q-wave MI developed, the rate of TIMI grade 3 flow was higher, peak creatine kinase level was lower, mean left ventricular ejection fraction was greater, corrected TIMI frame counts (CTFCs) were lower (ie, faster blood flow), and chest pain duration after thrombolytic administration was shorter. Patients in whom non-Q-wave MI developed less frequently underwent a percutaneous coronary intervention (PCI), and when they did, they had faster post-PCI CTFCs and higher rates of post-PCI TIMI grade 3 flow. Patients in whom a non-Q-wave MI developed had lower rates of severe recurrent ischemia. There were no differences in 30-day or in-hospital mortality rates or recurrent MI between patients with Q-wave MI and patients with non-Q-wave MI.

Conclusion

After thrombolytic therapy in STEMI with or without abciximab, ejection fractions were higher, the duration of ischemia was shorter, and coronary blood flow at both 90 minutes and after PCI was faster in patients who sustained non-Q-wave MI than in patients who sustained Q-wave MI. No differences in mortality or recurrent MI rates were detected in patients who sustained a Q-wave MI and patients in whom a Q-wave MI did not evolve in the modern thrombolytic era.     

Glycoprotein IIb/IIIa inhibitors during rescue percutaneous coronary intervention in acute myocardial infarction

Although percutaneous coronary intervention (PCI) following full-dose thrombolytic therapy (rescue angioplasty) is a common procedure, there is ample controversy regarding the usefulness of the procedure. Moreover, few data are available concerning the safety and efficacy of concomitant treatment with glycoprotein (GP) IIb/IIIa inhibitors in these patients. The aim of the present study was to compare the clinical outcomes of patients who underwent rescue PCI with stents and were treated with GP IIb/IIIa inhibitors. A total of 59 consecutive patients underwent rescue PCI at our institution during the study period, 29 patients (49.2%) were treated concomitantly with a GP IIb/IIIa inhibitor and 30 patients (50.8%) were not. Baseline clinical characteristics were similar between the two groups. In-hospital outcomes regarding death, reinfarction and the need for urgent target vessel revascularization was significantly lower in patients treated with GP IIb/IIIa inhibitors compared to those who were not treated (3.4% vs. 26.7%; p = 0.01, respectively). However, GP IIb/IIIa inhibitor administration was not an independent predictor of better outcomes by multivariate analysis. There was a higher rate of major bleeding complications in patients who received GP IIb/IIIa inhibitors, though it did not achieve statistical significance (6.9% vs. 0%; p = 0.14, respectively). The composite endpoint of major, minor bleeding and vascular complications was similar in both groups (24.1% vs. 16.7%; p = 0.48). In conclusion, the administration of GP IIb/IIIa inhibitors in patients undergoing rescue PCI after failed thrombolysis with stents was safe and may have a beneficial effect on 30-day event-free survival rates, without a significant increase in bleeding or vascular complications. These results warrant further investigation.     

Safety and feasibility of X-sizer-facilitated rescue percutaneous coronary intervention: a preliminary experience

Failed thrombolysis following ST-elevation myocardial infarction (STEMI) is associated with a poor prognosis. Rescue balloon angioplasty with or without stent implantation is an established treatment for failed thrombolysis. Recently, X-Sizer thrombectomy has been shown to be effective in removing intracoronary thrombi and improving coronary perfusion in patients with acute coronary syndrome. In this retrospective study, we sought to evaluate the safety and feasibility of X-Sizer-facilitated rescue percutaneous coronary intervention (PCI) for the treatment of STEMI after failed thrombolysis. Clinical data are from a retrospective review of 95 patients who underwent X-Sizer-facilitated primary PCI (n = 80) or rescue PCI (n = 15) during the period from November 2000 to February 2003. Baseline and procedural characteristics of the 2 groups were similar, except for a higher prevalence of hypercholesterolemia in the rescue PCI group. Angiographic success was achieved in 96% in the primary PCI group and 100% in the rescue PCI group. The 30-day mortality (7.5% vs. 13.3%), major acute coronary event (MACE; 7.5% vs. 13.3%), and MACE with angina (15% vs. 13.3%) rates were similar between the primary PCI and the rescue PCI groups. Similarly, the 6-month mortality (10% vs. 13.3%), MACE (16.3% vs. 13.3%) and MACE with angina (25% vs. 26.7%) rates were also comparable (p = NS for all comparison). In particular, there were no incidences of death, reinfarction or repeat revascularization between 30 days and 6 months in the rescue PCI group. In conclusion, X-Sizer-facilitated rescue PCI was safe and feasible. The outcomes of patients who underwent X-Sizer-facilitated rescue PCI were similar to those who underwent X-Sizer-facilitated primary PCI.     

Is transport with platelet GP IIb/IIIa inhibition for primary percutaneous coronary intervention more efficient than on-site thrombolysis in patients with STEMI admitted to community hospitals? Randomised study. Early results

INTRODUCTION: The advantage of primary percutaneous coronary intervention (pPCI) in the management of ST-elevation myocardial infarction (STEMI) over thrombolytic therapy has been demonstrated. However, an optimal medical treatment of STEMI patients admitted to regional hospitals without catheterisation facilities has not yet been established. Delay in initiation of pPCI resulting from transportation to the catheterisation laboratory may diminish the benefits of such therapy in comparison with thrombolysis administered in a regional hospital. Early initiation of therapy with platelet glycoprotein IIb/IIIa receptor inhibitor, which provides protection for the transportation, may be a reasonable solution to maintain the advantage of pPCI over thrombolysis alone in STEMI patients. METHODS: The studied group comprised patients with STEMI (infarct duration time <12 hours, typical clinical and electrocardiographic criteria of MI) who were randomly assigned in 13 regional hospitals located 20 to 150 km from invasive centre to one of two subgroups, either to thrombolysis in the community hospital or to transport after thrombolysis initiation with platelet GP IIb/IIIa receptor inhibitor (tirofiban; 10 mg/kg in intravenous bolus in the emergency room of the community hospital followed by continuous intravenous infusion of 0.1 mg/kg/min during transport as well as coronary procedure) in order to receive pPCI. All patients with cardiogenic shock on admission were routinely treated with PCI and were excluded from the study. RESULTS: 341 patients were included in the study (169 were randomised to receive thrombolytic therapy and 172--transport with intention to perform PCI). Mean time between onset of MI and randomisation was similar in the transport and thrombolysis groups, (139+/-133 min. vs 143+/-117 min., respectively, p=0.94). Mean infusion time of tirofiban to the beginning of PCI in the transport group was 121+/-36 min. Anterior MI was present in 42.6% of patients in the PCI group and in 41.5% in the thrombolytic group (p=0.085). Mean time from randomisation to pPCI was 158+/-60 min., and to thrombolysis initiation in 44+/-43 min. (p <0.0001). None of the patients died during transfer. In a 30-day follow-up we noted (pPCI vs thrombolytic group, respectively): mortality 3.49% vs 8.88% (p=0.04); reinfarction 1.16% vs 5.92% (p=0.02), stroke 0.58% vs 1.18% (p=0.55). In-hospital stay was significantly shorter in the transport group (9+/-3 days vs 14+/-7 days, p <0.0001). During hospitalisation, 17 (10.05%) patients initially assigned to thrombolysis alone had to be transferred to the catheterisation laboratory to undergo PCI (rescue PCI or PCI for postinfarction angina). Combined end-point (death/reinfarction/stroke) was reached more frequently in the thrombolytic group (15.98% vs 5.23%, p=0.001). CONCLUSIONS: A strategy of invasive therapy involving transport with GP IIb/IIIa receptor inhibitor and pPCI in STEMI patients admitted to hospital without catheterisation facilities was found to be more effective than thrombolytic therapy alone employed in the regional hospitals.     

Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction

OBJECTIVES: We sought to evaluate and validate the ability of the angiographic myocardial blush grade to risk stratify patients after successful angioplasty in acute myocardial infarction (AMI). BACKGROUND: Although epicardial Thrombolysis In Myocardial Infarction (TIMI)-3 flow is restored in >90% of patients undergoing primary percutaneous coronary intervention (PCI), normal myocardial perfusion may be present less frequently and may detrimentally impact survival. METHODS: A cohort of 173 consecutive patients undergoing intervention within 24 h of AMI onset were studied. High-risk features of this population included failed thrombolysis in 39%, cardiogenic shock in 17% and saphenous vein graft culprit in 11% of patients. RESULTS: Despite the restoration of TIMI-3 flow in 163 (94.2%) patients, myocardial perfusion, as evidenced by normal contrast opacification of the myocardial bed subtended by the infarct artery (myocardial blush), was normal in only 29.4% of patients with TIMI-3 flow following PCI, and in no patient with TIMI 0 to 2 flow. In patients in whom TIMI-3 flow was restored, survival was strongly dependent on the myocardial perfusion grade; one-year cumulative mortality was 6.8% with normal myocardial blush, 13.2% with reduced myocardial blush and 18.3% in patients with absent myocardial blush (p = 0.004). CONCLUSIONS: Abnormal myocardial perfusion is present in most patients following primary or rescue PCI in AMI, despite restoration of brisk epicardial coronary flow. In high risk patients achieving TIMI-3 flow after intervention, the myocardial blush score may be used to stratify prognosis into excellent, intermediate and poor survival. Further study is warranted to examine whether adjunctive mechanical or pharmacologic strategies can further improve myocardial perfusion and survival of patients with acute myocardial infarction undergoing intervention.     

Percutaneous coronary intervention in cardiogenic shock complicating acute ST-elevation myocardial infarction-a single centre experience

BackgroundMortality in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) approaches 70 – 80%, regardless of the type of pharmacological treatment. Early revascularisation improves survival in AMI with CS. Our aim is to assess the predictors of mid-term outcome after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and CS.MethodsForty-one patients who underwent primary or rescue PCI for CS were analysed comparing their baseline, angiographic, PCI data, 30-day and 1-year survival.ResultsThere were no significant differences between survivors and non-survivors in baseline characters, except for more number of transfer admissions (P= 0.0005), and cardiopulmonary resuscitations (P= 0.015) in the later group. The mean time between myocardial infarction (MI) onset to shock and MI onset to revascularisation were 12.8 ± 12.9 hours and 17.0 ± 16.8 hours, respectively. Patients with better pre-procedure thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery (IRA) had better survival (P= 0.0005). Successful PCI was achieved in 48.8% of patients. The 30-day mortality was 56.1% and all were prior to hospital discharge. Patients with successful PCI had better short-term survival in comparison with patients with failed PCI (80% vs 9.6%). Eighteen patients who survived at 30 days were followed up for 12–72 months (mean 28.5 ± 5.4 months). Fifteen patients survived at 1 year after PCI and all were in good functional status.ConclusionMortality remains high even with PCI. Achieving IRA patency with TIMI 3 flow is the main determinant of survival. Survival and functional status are good in patients who are discharged from hospital.     

Characteristics and mortality following primary percutaneous coronary intervention for acute myocardial infarction in Spain. Results from the TRIANA 1 (TRatamiento del Infarto Agudo de miocardio eN Ancianos) Registry

INTRODUCTION AND OBJECTIVES: Although more elderly patients will experience acute myocardial infarction (AMI) in coming years, the best reperfusion strategy in these patients remains unknown. PATIENTS AND METHOD: The Spanish TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) registry was set up to determine the feasibility of performing a randomized study of percutaneous coronary intervention (PCI) versus thrombolysis in AMI patients aged > or =75 years. The TRIANA 1 subregistry included consecutive patients of all ages with ST-segment-elevation AMI (< or =12 h from onset) who underwent PCI in selected hospitals. RESULTS: In total, 459 TRIANA-1 patients were included at 25 hospitals over 3 months. Some 11% had cardiogenic shock. PCI was performed as rescue therapy in 24% and, in 15% because thrombolysis was contraindicated. After PCI, 83% had TIMI grade-3 flow without significant residual stenosis. Mortality at 1 month was 10.8%. Independent predictors of mortality identified by multivariate analysis were: cardiogenic shock at admission (OR, 7.2, 95% CI, 2.2-23.3), age (OR, 1.05 per year, 95% CI, 1.005-1.100), maximum creatine kinase MB fraction (OR, 1.01, 95% CI, 1.004-1.270) and post-PCI TIMI grade <3 (OR, 2.8, 95% CI, 1.0-8.3). Of 104 participants aged > or =75 years (mortality, 24%), 58 (55.7%) fulfilled criteria for inclusion in a randomized study. CONCLUSIONS: 1) The TRIANA 1 subregistry probably reflects the reality of PCI for AMI in Spain. 2) Mortality at 1 month was associated with classic predictive factors. 3) Some 50% of patients > or =75 years old who underwent PCI could be included in a randomized study. These findings indicate that randomized study to determine the best reperfusion strategy in elderly AMI patients is feasible.     

Effect of no-reflow during primary percutaneous coronary intervention for acute myocardial infarction on six-month mortality

No-reflow is a frequent event during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), and it may affect cardiac prognosis. We evaluated the occurrence of no-reflow as a predictor of outcomes in patients who underwent PCI for AMI. We prospectively collected data from 599 consecutive patients who underwent stent-based PCI for ST-elevation AMI by identifying those with no-reflow (Thrombosis In Myocardial Infarction [TIMI] grade <3 flow at completion of the procedure) and analyzing their baseline characteristics and clinical outcomes. Patients with no-reflow (n = 40, 6.7%) were older (67 +/- 13 vs 60 +/- 13 years, p = 0.002) and had longer ischemic times (5.5 +/- 3.7 vs 4.4 +/- 3.0 hours, p = 0.04) with more TIMI grade 0/1 flow at presentation (90% vs 64%, p = 0.001). No-reflow occurred mostly (73%) after stenting and often required intra-aortic balloon pump counterpulsation (30% vs 4.3%, p <0.001). Peak creatine kinase level was higher in patients with no-reflow (2,700 +/- 1,900 vs 2,000 +/- 1,800, p = 0.03) and more often associated with moderate or severe left ventricular dysfunction (68% vs 45%, p = 0.006) and increased 6-month mortality (12.5% vs 4.3%, p = 0.04). By multivariate analysis, no-reflow was an independent predictor of long-term mortality (odds ratio 3.4, p = 0.02). In addition, renal failure (odds ratio 4.39, p = 0.0025) and preprocedure TIMI grade 0/1 flow (odds ratio 2.1, p = 0.003) were independent predictors of no-reflow. In conclusion, the association of no-reflow with longer ischemic time and worse initial TIMI flow may indicate the presence of highly organized thrombus burden with higher propensity for distal embolization. Regardless of its mechanism, no-reflow was an independent predictor of increased mortality.     

溶栓后早期转运PCI与保守治疗/补救转运PCI治疗STEMI患者的比较

目的：本研究回顾分析比较急性心肌梗塞（AMI）患者在基层医院行溶栓治疗后,早期转运到上级医院行经皮冠状动脉介入治疗（PCI）和继续在当地予保守治疗然后作转运PCI的优劣。方法：315例AMI患者在发病12h内,于基层医院接受溶栓治疗,其后183例直接转诊行PCI（A组）,132例在当地继续保守治疗,67例因再次出现心肌缺血症状行补救性转运PCI（B组）。比较两组1年内全因死亡、再梗死、难治性心肌缺血发生率及30d内严重出血和脑卒中发生率,以及治疗前后左室射血分数（LVEF）改变情况。结果：与B组比较,A组1年内全因死亡率（6.8%比1.6%）、再梗死发生率（17.4%比3.3%）、难治性心肌缺血发生率（22.7%比4.4%）均明显降低（P均〈0.05）,而LVEF改善情况A组明显优于B组[（58.7±12.4）%比（47.6±11.9）%,P〈0.05]。结论：溶栓后的ST段抬高性心肌梗死患者应尽早转运到上级医院接受PCI治疗,以取得更好疗效。     

The impact of GP IIb/IIIa inhibitors during primary percutaneous coronary intervention in acute myocardial infarction patients

The use of glycoprotein (GP) IIb/IIIa inhibitors during percutaneous coronary interventions (PCI) in the acute phase of myocardial infarction (AMI) is still a matter of debate. The aim of the present study was to compare the outcomes of patients with acute ST-segment elevation myocardial infarction who underwent primary PCI and were concomitantly treated with GP IIb/IIIa inhibitors with those who were not treated with these drugs. Between January 1996 and November 2003, a total of 418 consecutive patients underwent PCI in the setting of ST-segment elevation AMI. At the operator's discretion, 287 patients were concomitantly treated with GP IIb/IIIa inhibitors and 115 patients were not. Angiographic success and final TIMI 3 flow in the infarct-related artery was achieved more frequently in patients treated with GP IIb/IIIa inhibitors (90% vs. 77%; p=0.001). The in-hospital composite endpoint of death, reinfarction and bleeding complications was significantly better in patients treated with GP IIb/IIIa inhibitors (4% vs. 12%; p=0.005). Furthermore, the adjusted 12-month survival rate was significantly better in these patients (RR: 2.99, CI: 1.29-6.9; p=0.01). Therefore, adjunctive therapy with GP IIbIIIa inhibitors during primary PCI is associated with improved short-term outcomes and one-year survival without an increased risk of bleeding.     

Rescue percutaneous coronary intervention for failed thrombolysis.

BACKGROUND: Previous studies of rescue percutaneous coronary intervention (PCI) for failed thrombolysis yielded conflicting results. In the current era of newer thrombolytic agents, coronary stents, glycoprotein IIb/IIIa inhibitors, and aggressive hemodynamic support, the outcome of this high-risk patient group has not been characterized. METHODS: From January 2000 to October 2004, 214 consecutive patients were transferred and underwent emergent coronary angiography following failed thrombolysis. One hundred and fifty five (72%) underwent immediate PCI, 23 (11%) underwent delayed PCI, and 36 (17%) received surgical revascularization or medical therapy. Medical records and angiograms for the entire PCI cohort (n=178) were reviewed for in-hospital events including bleeding complications, stroke, recurrent ischemia or myocardial infarction (MI), target vessel revascularization (TVR), and death. RESULTS: Time from symptom onset to thrombolysis (mean +/- standard deviation) was 5.6 +/- 11.9 hr, and time from thrombolysis to angiography was 7.0 +/- 5.5 hr. The study cohort was critically ill, with 9.6% experiencing cardiac arrest, 21% in cardiogenic shock, and 12% intubated prior to transfer. Coronary stents were placed in 88%, Rheolytic thrombectomy was used in 21%, an intraaortic balloon pump was placed in 17%, and a glycoprotein IIb/IIIa inhibitor was administered in 92%. Patients receiving delayed PCI had higher TIMI 3 flow grade at initial angiography than those receiving immediate PCI (83% vs. 34%, respectively, P < 0.0001). Angiographic success was 90% for the entire PCI cohort, 89% for the immediate PCI group, and 100% for the delayed PCI group. Clinical success (angiographic success and freedom from major adverse cardiac events) was 85% for the entire PCI cohort, 83% for the immediate PCI group, and 100% for the delayed PCI group. Severe and moderate bleeding complications occurred in 7.3%, stroke in 1.7%, recurrent ischemia or MI in 7.3%, and TVR in 3.4%. Overall, in-hospital mortality for the entire PCI cohort was 3.4%. CONCLUSIONS: This observational, consecutive, real-world study of contemporary rescue PCI for failed thrombolysis shows a high use of coronary stents, Rheolytic thrombectomy, glycoprotein IIb/IIIa inhibitors, and intraaortic balloon pump placement. Angiographic and clinical success was high with low bleeding complications and low in-hospital mortality, suggesting that prospective, randomized trials using contemporary interventional therapy for rescue PCI be considered.     

Prognostic value of circulating levels of endothelin-1 in patients after acute myocardial infarction undergoing primary coronary angioplasty

BACKGROUND: The link between increased circulating level of endothelin (ET)-1 and adverse clinical outcomes after acute myocardial infarction (AMI) has been established. Current studies demonstrate that reperfusion therapy by either thrombolysis or primary percutaneous coronary intervention (PCI) can salvage myocardium, improving survival of AMI patients. However, whether reperfusion therapy by primary PCI can prevent the adverse effect of ET-1 on clinical outcomes in patients after AMI remains unclear. Therefore, this study examined the predictive value of circulating ET-1 levels on 30-day outcomes in ST-segment elevated AMI treated with primary PCI. METHODS AND RESULTS: We conducted a prospective cohort study of 186 consecutive patients with ST-segment elevated AMI of onset < 12 h who underwent primary PCI. Blood samples for plasma concentration of ET-1 were collected in the catheterization laboratory following vascular puncture. Patients were classified into a high group (group 1, ET-1 level >or= 0.632 pg/mL, n = 93) and a low group (group 2, ET-1 level < 0.632 pg/mL, n = 93) according to the median value of ET-1 after AMI. Univariate analysis demonstrated that the 30-day composite major adverse clinical outcomes (MACO) [advanced Killip score >or= 3], severe congestive heart failure (CHF) [New York Heart Association functional class 4], and 30-day mortality were strongly associated with high ET-1 level (>or= 0.632 pg/mL; p < 0.0001), unsuccessful reperfusion (final Thrombolysis in Myocardial Infarction flow 相似文献