Acute Reperfusion Therapy Research Articles

Reperfusion therapies of acute ischemic stroke: potentials and failures.

Over the past 20 years, clinical research has focused on the development of reperfusion therapies for acute ischemic stroke (AIS), which include the use of systemic intravenous thrombolytics (alteplase, desmoteplase, or tenecteplase), the augmentation of systemic intravenous recanalization with ultrasound, the bridging of intravenous with intra-arterial thrombolysis, the use of multi-modal approaches to reperfusion including thrombectomy and thromboaspiration with different available retrievers. Clinical trials testing these acute reperfusion therapies provided novel insight regarding the comparative safety and efficacy, but also raised new questions and further uncertainty on the field. Intravenous alteplase (tPA) remains the fastest and easiest way to initiate acute stroke reperfusion treatment, and should continue to be the first-line treatment for patients with AIS within 4.5 h from onset. The use of tenecteplase instead of tPA and the augmentation of systemic thrombolysis with ultrasound are both novel therapeutical modalities that may emerge as significant options in AIS treatment. Endovascular treatments for AIS are rapidly evolving due to technological advances in catheter-based interventions and are currently emphasizing speed in order to result in timely restoration of perfusion of still-salvageable, infarcted brain tissue, since delayed recanalization of proximal intracranial occlusions has not been associated with improved clinical outcomes. Comprehensive imaging protocols in AIS may enable better patient selection for endovascular interventions and for testing multi-modal combinatory strategies.

ATRIAL FIBRILLATION IN STEMI PATIENTS: CONTEMPORARY MANAGEMENT AND ONE YEAR OUTCOMES

abetics, 19% Killip 4, and 77% undergoing primary PCI. The proportions taking 4/4 medication classes at discharge were 73.6% and 75.5% in intervention and control arms, respectively. At 12 months, proportions were 58.4% and 58.9% in the intervention and control group, respectively, (model-based OR 1.1, 95% CI 0.83-1.45). The process evaluation indicates that 51% of patients remembered receiving the intervention, and of these 52% took it for discussion with their health care provider. Patients reported that discontinuation of medication was most commonly at the direction of the internist/cardiologist (64%), and due to medication-related side-effects (62%). Discussion: DERLA-STEMI demonstrates the feasibility of recruiting and randomizing all eligible STEMI patients in a provincial health region. Preliminary results suggest low persistence to all 4 cardiac medication classes at 12-months. There was no significant difference in the use of guidelinerecommended medications post-STEMI in patients (and their family physicians) receiving delayed and repeated reminders as compared to usual care. HHS

Comparative efficacy of different acute reperfusion therapies for acute ischemic stroke: a comprehensive benefit-risk analysis of clinical trials.

BackgroundNumerous acute reperfusion therapies (RPT) are currently investigated as potential new therapeutic targets in acute ischemic stroke (AIS). We conducted a comprehensive benefit–risk analysis of available clinical studies assessing different acute RPT, and investigated the utility of each intervention in comparison to standard intravenous thrombolysis (IVT) and in relation to the onset-to-treatment time (OTT).MethodsA comprehensive literature search was conducted to identify all available published, peer-reviewed clinical studies that evaluated the efficacy of different RPT in AIS. Benefit-to-risk ratio (BRR), adjusted for baseline stroke severity, was estimated as the percentage of patients achieving favorable functional outcome (BRR1, mRS score: 0–1) or functional independence (BRR2, mRS score: 0–2) at 3 months divided by the percentage of patients who died during the same period.ResultsA total of 18 randomized (n = 13) and nonrandomized (n = 5) clinical studies fulfilled our inclusion criteria. IV therapy with tenecteplase (TNK) was found to have the highest BRRs (BRR1 = 5.76 and BRR2 = 6.82 for low-dose TNK; BRR1 = 5.80 and BRR2 = 6.87 for high-dose TNK), followed by sonothrombolysis (BRR1 = 2.75 and BRR2 = 3.38), while endovascular thrombectomy with MERCI retriever was found to have the lowest BRRs (BRR1 range, 0.31–0.65; BRR2 range, 0.52–1.18). A second degree negative polynomial correlation was detected between favorable functional outcome and OTT (R2 value: 0.6419; P < 0.00001) indicating the time dependency of clinical efficacy of all reperfusion therapies.ConclusionIntravenous thrombolysis (IVT) with TNK and sonothrombolysis have the higher BRR among investigational reperfusion therapies. The combination of sonothrombolysis with IV administration of TNK appears a potentially promising therapeutic option deserving further investigation.

Relationship between care gaps and projected life expectancy after acute myocardial infarction.

Higher-risk patients may not receive evidence-based therapy because of limited life expectancy, which is a composite measure that encompasses many patient factors, including age, frailty, and comorbidities. In this study, we evaluated the extent to which treatment care gaps can be explained by a difference in projected life expectancy. An observational cohort study was conducted on acute myocardial infarction patients hospitalized in Ontario, Canada. Projected life expectancy was estimated using actual survival data with extrapolation using proportional hazard models adjusting for important covariates. The relationship between projected life expectancy with statins and reperfusion therapy was examined using generalized linear models. Among the 7001 acute myocardial infarction patients, 84.3% were prescribed statins and 72.9% were treated with reperfusion therapy. When projected life expectancy was <10 years, the likelihood of receiving either treatment declined progressively with reduction in life expectancy (P<0.001). At the 25th percentile of projected life expectancies, the likelihood of receiving a statin decreased by 1.4% (95% confidence interval, 1.0-1.8%), and acute reperfusion therapy decreased by 2.6% (95% confidence interval, 1.8-3.3%) for each year decline in projected life expectancy. Life expectancy of a patient strongly influences evidence-based treatment in acute myocardial infarction. It was seen not only among patients with limited life expectancies but also among those with many years to live. Treatment care gaps may reflect clinicians' synthesis about frailty and life-expectancy gains.

Updated electrocardiographic classification of acute coronary syndromes.

The electrocardiogram (ECG) findings in acute coronary syndrome should always be interpreted in the context of the clinical findings and symptoms of the patient, when these data are available. It is important to acknowledge the dynamic nature of ECG changes in acute coronary syndrome. The ECG pattern changes over time and may be different if recorded when the patient is symptomatic or after symptoms have resolved. Temporal changes are most striking in cases of ST-elevation myocardial infarction. With the emerging concept of acute reperfusion therapy, the concept ST-elevation/non-ST elevation has replaced the traditional division into Q-wave/non-Q wave in the classification of acute coronary syndrome in the acute phase.Keypoints: In acute coronary syndrome, in addition to the traditional electrocardiographic risk markers, such as ST depression, the 12-lead ECG contains additional, important diagnostic and prognostic information. Clinical guidelines need to acknowledge certain high-risk ECG patterns to improve patient care.

Stroke- on- Awakening: Safety of CT-CTA Based Selection for Reperfusion Therapy

We studied the safety of use of acute reperfusion therapies in patients with stroke- on- awakening using a computed tomographic angiography (Cta) based large vessel occlusion-good scan paradigm in clinical routine. the Cta database of the Calgary stroke program was reviewed for the period January 2003-March 2010. patients with stroke-on-awakening with large artery occlusions on Cta, who received conservative, iV thrombolytic and/or endovascular treatment at discretion of the attending stroke neurologist were analyzed. time of onset was defined by the time last seen or known to be normal. Baseline non-contrast Ct scan (nCCt) alberta Stroke program early Ct Score (aSpeCtS) > 7 was considered a good scan. hemorrhage was defined on follow-up brain imaging using eCaSS 3 criteria. independence (mrS≤2) at three months was considered a good clinical outcome. Standard descriptive statistics and multivariable analysis were done. among 532 patients with large artery occlusions, 70 patients with stroke-on-awakening (13.1%) were identified. the median age was 69.5 (iQr 24) and 41 (58.6%) were female; 41 (58.6%) received anti-platelets only and 29 (41.4%) received thrombolytic treatment [iV-12 (17.1%), iV/ia-12 (17.1%) and ia-5(7.1%)]. unadjusted analysis showed that baseline nCCt aSpeCtS ≤ 7 (p=0.002) and higher nihSS scores (p=0.018) were associated with worse outcomes. there were no ph2 hemorrhages in the iV thrombolytic or endovascular treated group. functional outcome was not different by treatment. When carefully selected using Ct –Cta, by a good scan (aSpeCtS > 7) occlusion paradigm, acute reperfusion therapies in patients with stroke-on-awakening can be performed safely in clinical routine.

Abstract 77: Comparative Efficacy of Different Acute Reperfusion Therapies for Acute Ischemic Stroke: A Comprehensive Meta-analysis of Clinical Trials

Background&amp;Purpose: There are limited data directly comparing acute reperfusion therapies (RPT) for the treatment of acute ischemic stroke (AIS) in the setting of randomized controlled trials. We conducted a comprehensive meta-analysis of available clinical studies of acute RPT to indirectly compare them using a benefit-to-risk analysis. Subjects&amp;Methods: We abstracted data from 16 RPT studies evaluating intravenous thrombolysis (IVT) using alteplase or tenecteplase (TAAIS, NINDS), sonothrombolysis (CLOTBUST) intra-arterial thrombolysis (PROACT I&amp;II, IMS III, SYNTHESIS pilot&amp;expansion study) and acute thrombectomy/thromboaspiration using different retrievers (MERCI, Multi-MERCI, PENUMBRA Pivotal Stroke Trial &amp; Post Market Experience, SWIFT, TREVO, TREVO 2, MR Rescue). The benefit-to-risk ratio (BRR) was estimated separately for each study using the following formula: BRR= (% of 3-month mRS of 0-1/ % of 3-month mRS of 6) x (median baseline NIHSS of study of interest/median baseline NIHSS of all evaluated studies). Results: The BRRs of all analyzed studies (median pre-treatment NIHSS 17 points) plotted against time to intervention are shown in Figure. The BRRs ranged from 0.31 in the MR Rescue endovascular arm to 5.80 in the high-dose of tenecteplase in TAAIS. The most effective RPTs were: IVT with tenecteplase in TAAIS (BRR 5.80), sonothrombolysis (BRR 2.75), followed by IVT with alteplase in SYNTHESIS expansion trial (BRR 2.68). The endovascular arm of TREVO had the highest BRR (1.70) among the acute thrombectomy studies evaluating different devices. BRR strongly correlated with time to treatment from symptom onset (R2:0.640; p&lt;0.0001) Conclusions: IVT with a novel agent followed by sonothrombolysis appear to be associated with the highest BRR. Almost two thirds of the variation of BRR can be explained by differences in onset-to-treatment time between studies indicating a strong time-dependency of BRR in acute RPT.

Abstract T P13: Reversed Ischemic Attack (Ria): Proposal for a New Terminology in the Era of Thrombolytic Therapy

Background and Purpose: Cerebral ischemic attacks are classically known to cause either permanent injury in the case of ‘stroke’ or transient dysfunction without permanent injury in the case of ‘TIA’. The latter occurs due to timely restoration of cerebral blood flow and implies a spontaneous process. With thrombolytic therapy (intravenous or intra-arterial) complete reperfusion is possible and can lead in some patients to complete reversal of the ischemic insult both clinically and radiographically. This entity is inadequately characterized by the current stroke terminology. Methods: A retrospective review of a prospectively maintained database identified 800 patients who underwent acute endovascular reperfusion therapy. Inclusion criteria were: complete clinical recovery without evidence of infarction on follow up MRI (DWI sequence). Results: We identified 8 patients. Intravenous alteplase followed by intra-arterial therapy was administered in 37.5% of cases. Admission NIHSS ranged from 8-21 and recanalization occurred between 45-490 minutes of symptom onset. The site of occlusion was as follows: left internal carotid artery terminus (2, 25%), middle cerebral artery M1 segment (5, 62.5%) and middle cerebral artery M2 segment (1, 12.5%). Conclusions: A hitherto unreported condition of complete clinical and radiographic recovery after reperfusion therapy for large vessel intracranial occlusion is being described. Review of an endovascular database comprising 800 consecutive cases, revealed that the incidence of this entity is 1%. We postulate that in parallel to an increase in efficacy and utilization of revascularization modalities along with an increase in assessment of vessel patency prior to intravenous thrombolysis, recognition of this phenomenon will increase and propose the term ‘Reversed’ Ischemic Attack (RIA) to address a deficiency in terminology currently associated with this condition.

Advances in Stroke

Substantial advances have been made during the past 2 years in various applications of neuroimaging in stroke. Because of limited space, a few major areas in imaging are highlighted here, including developments in selection for acute stroke therapies, hemorrhage, and recovery. Results from several clinical trials have provided important data about imaging selection, including the mismatch concept, for acute stroke reperfusion therapies. A post hoc analysis of the pooled EPITHET-DEFUSE (Echoplanar Imaging Thrombolytic Evaluation Trial and Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study) datasets found that alteplase in the 3- to 6-hour window attenuated infarct growth and increased reperfusion in mismatch patients compared with placebo. Clinical outcomes were associated with degree of reperfusion; however, there was no difference in mortality or outcome between treatment groups and no comparison with nonmismatch patients.1,2 Another secondary pooled analysis from all 3 of the desmoteplase trials suggested that defining mismatch with a minimum volume of 60 cc based on magnetic resonance imaging (MRI) alone showed a significant treatment effect for desmoteplase.3 Additionally, in patients with a visible occlusion on noninvasive vessel imaging at baseline, the …

Intravenous thrombolysis for acute ischemic stroke: past, present and future

The efficacy of intravenous thrombolysis using alteplase, a recombinant tissue plasminogen activator (IV t-PA) within a 4.5-hour time window for acute ischemic stroke patients has been well established. However, a tight time window allows a minority of stroke patients to receive IV t-PA, and low recanalization rates of large intracranial artery occlusions limit the efficacy of IV t-PA. To overcome the limitations of IV t-PA, clinical trials regarding IV t-PA based on DWI-PWI mismatch or DWI-FLAIR mismatch, next-generation agents of t-PA, dose modification of alteplase, sonothrombolysis, and so on are going on worldwide. Shortening of the time of door to treatment (needle or femoral puncture) plays a very important role to enhance the efficacy of acute reperfusion therapy including IV t-PA and acute stroke endovascular therapy, and as a consequence, it could contribute to improve the entire stroke outcomes due to an increase of acute reperfusion therapy-eligible patients.

Abstract 18442: Long-Term Prognostic Value of Cardiac Magnetic Resonance and Echocardiography After Reperfusion Therapy in ST-Segment Elevation Myocardial Infarction

Background: The aim of this study was to determine whether adding DE-CMR and/or TTE based parameters beyond known clinical factors provides incremental improvement of predicting long-term outcomes in STEMI patients who undergo acute reperfusion therapy. Methods and Results: One hundred twenty patients with first time STEMI who underwent PCI (74%), fibrinolysis (3%), and both (19%), were studied by both delayed enhancement cardiac magnetic resonance (DE-CMR) and transthoracic echocardiogram (TTE) during the acute phase of myocardial infarction. The primary endpoint was major adverse cardiac events (MACE). There were 28 events (6 deaths, 13 recurrent ischemia, and 9 heart failure) over a median follow-up of 4 years. We defined incremental increase in prognostic value by increase in Cox proportional hazards global chi square (χ 2 ) and/or increase in c-index with the addition of TTE and/or CMR parameters after adjusting for clinical variables. Among the clinical data, heart rate (HR: 1.02, p=0.047) and troponin (HR: 1.13, p=0.013) predicted MACE (χ 2 : 12.4, P=0.002; C index 0.69). After adjusting for these clinical factors, adding TTE parameters (left ventricular end systolic volume index [HR: 1.05, p&lt;0.0001] and mitral valve deceleration time [HR: 0.99, p=0.036]), increased the global χ 2 to 24.6 and C index to 0.74 (p&lt;0.0001). When CMR parameter (infarct size [HR: 2.92, p&lt;0.0001]) was added to the clinical data alone, there was greater increase in global χ 2 to 36.8 and C index to 0.83 (p&lt;0.0001). Addition of DE- CMR to clinical data combined with TTE measures showed significant incremental value with increased χ 2 difference of 17.6 (p&lt;0.0001). There was no significant incremental value of adding TTE to clinical data combined with DE-CMR (p&gt;0.05). Conclusion: DE-CMR provides significant incremental value for prognosticating adverse cardiac events over clinical data alone (or when in combination with TTE) in STEMI patients who undergo reperfusion therapy.

Clinical application of perfusion computed tomography in neurosurgery

Currently, perfusion CT (PCT) is a valuable imaging technique that has been successfully applied to the clinical management of patients with ischemic stroke and aneurysmal subarachnoid hemorrhage (SAH). However, recent literature and the authors' experience have shown that PCT has many more important clinical applications in a variety of neurosurgical conditions. Therefore, the authors share their experiences of its application in various diseases of the cerebrovascular, neurotraumatology, and neurooncology fields and review the pertinent literature regarding expanding PCT applications for neurosurgical conditions, including pitfalls and future developments. A pertinent literature search was conducted of English-language articles describing original research, case series, and case reports from 1990 to 2011 involving PCT and with relevance and applicability to neurosurgical disorders. In the cerebrovascular field, PCT is already in use as a diagnostic tool for patients suspected of having an ischemic stroke. Perfusion CT can be used to identify and define the extent of the infarct core and ischemic penumbra core, and thus aid patient selection for acute reperfusion therapy. For patients with aneurysmal SAH, PCT provides assessment of early brain injury, cerebral ischemia, and infarction, in addition to vasospasm. It may also be used to aid case selection for aggressive treatment of patients with poor SAH grade. In terms of oncological applications, PCT can be used as an imaging biomarker to assess angiogenesis and response to antiangiogenetic treatments, differentiate between glioma grades, and distinguish recurrent tumor from radiation necrosis. In the setting of traumatic brain injury, PCT can detect and delineate contusions at an early stage. In patients with mild head injury, PCT results have been shown to correlate with the severity and duration of postconcussion syndrome. In patients with moderate or severe head injury, PCT results have been shown to correlate with patients' functional outcome. Perfusion CT provides quantitative and qualitative data that can add diagnostic and prognostic value in a number of neurosurgical disorders, and also help with clinical decision making. With emerging new technical developments in PCT, such as characterization of blood-brain barrier permeability and whole-brain PCT, this technique is expected to provide more and more insight into the pathophysiology of many neurosurgical conditions.

Transcervical access in acute ischemic stroke

BackgroundLarge vessel occlusive disease portends a poor prognosis unless recanalization is rapidly achieved. Endovascular treatment is typically performed via a transfemoral approach, but catheterization of the occluded vessel can be...

Serum Uric Acid as a prognostic biomarker &amp; its correlation with Killip Class in Acute Myocardial Infarction

Introduction: Uric acid has been proven to be a negative prognostic indicator in patients with acute myocardial infarction and heart failure. There is a need to find a simple, less expensive but accurate marker that could be use in rural areas where fibrinolytic treatment is the first choice of acute reperfusion therapy. Materials and Methods: 80 patients presenting with acute myocardial infarction were included in the study and serum uric acid levels and Killip Class was assessed on Day 0,3 and 7. Results: Serum uric acid levels were raised in patients who presented with higher Killip Class on admission and all the 6 patients who succumbed belonged to either Killip Class 3 or 4 at presentation with a serum uric acid level of more than or equal to 7mg/dL. Conclusion: Serum uric levels are raised during an episode of myocardial infarction and more so when the patient is in heart failure. There is a positive correlation between rising serum uric acid levels with higher Killip Class at the time of admission. Thus uric acid can be used as a prognostic indicator in patients presenting with myocardial infarction more so if they are in heart failure.

Do clinical factors explain persistent sex disparities in the use of acute reperfusion therapy in STEMI in Sweden and Canada?

This study examined clinical factors associated with sex differences in the use of acute reperfusion therapy (fibrinolysis or primary percutaneous coronary intervention) in ST-elevation myocardial infarction (STEMI) patients, and the interaction between sex and these factors in Sweden and Canada. Patients with STEMI in Sweden (n=32,676 from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) were compared with similar patients in Canada (n=3375 from the Canadian Global Registry of Acute Coronary Events) for the period 2004-2008. Unadjusted vs. age-adjusted odds ratios (OR) for no reperfusion (women vs. men) were for Sweden 1.57 (95% CI 1.49-1.64) vs. 1.14 (95% CI 1.08-1.20), and for Canada 1.61 (95% CI 1.39-1.87) vs. OR 1.18 (95% CI 1.01-1.39). Sex differences persisted after multivariable adjustments (including prehospital delay, atypical symptoms, diabetes), factors for which no interaction with sex was found. Among women <60 years, adjusting for atypical symptoms in Canada and angiographic data in Sweden made the greatest contribution to explaining observed sex differences. In both countries, acute reperfusion therapy in STEMI was used less often in women than in men. Factors associated with these sex differences appear to differ between older and younger women. Targeted interventions are needed to optimize care for women with STEMI, as well as sex- and age-stratified reporting of quality indicators to assess their effectiveness.

MR RESCUE

The timely concurrent publication of Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) with the International Management of Stroke Trial III and the Local Versus Systemic Thrombolysis for Acute Ischemic Stroke (SYNTHESIS) Expansion trials confirmed that endovascular therapy was not superior to standard care for patients with acute ischemic stroke.1–3 The novel conclusion from MR RESCUE was that, …a favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular Some have interpreted this finding to support a pessimistic (glass half-empty) view of advanced imaging selection for acute reperfusion therapy. We disagree with this viewpoint and argue that the results of MR RESCUE should not dampen enthusiasm for the concept of imaging-based selection. Key limitations of MR RESCUE that hinder the generalizability of the conclusions of the study include enrollment bias, with a preponderance of patients having large infarct cores, and late times to endovascular therapy combined with very low rates of adequate early reperfusion. Lessons learned from this important study should help guide future trials. MR RESCUE was a phase IIb randomized, controlled, open-label, blinded outcome, multicenter study. Patients were assigned within 8 hours after the onset of large-vessel anterior circulation stroke to undergo embolectomy (with the first-generation Merci or Penumbra devices) or standard care (37% of patients received IV recombinant tissue plasminogen activator). Based on MRI (80%) or multimodal computed tomography, randomization was stratified according to whether the patient had a favorable penumbral pattern (infarct core <90 mL and substantial salvageable tissue) or a nonpenumbral pattern (large core and small or absent penumbra). Notably, only 118 patients eligible for the primary analyses were enrolled across 22 high-volume North American Stroke Centers over nearly a decade (2004–2011). The median predicted infarct core volume at the time of baseline …

026 TRENDS IN IN-HOSPITAL TREATMENTS, INCLUDING REVASCULARISATION, FOLLOWING ACUTE MYOCARDIAL INFARCTION, 2003–2010: A MULTI-LEVEL AND RELATIVE SURVIVAL ANALYSIS FOR THE NATIONAL INSTITUTE FOR CARDIOVASCULAR OUTCOMES RESEARCH (NICOR)

BackgroundIt is not known how survival has changed over time for patients who do and do not receive an early invasive strategy for the management of AMI.Table 1Patient characteristics by...

Impact of Cardiac Care Variation on ST-Elevation Myocardial Infarction Outcomes in Malaysia

Developing countries face challenges in providing the best reperfusion strategy for patients with ST-segment elevation myocardial infarction because of limited resources. This causes wide variation in the provision of cardiac care. The aim of this study was to assess the impact of variation in cardiac care provision and reperfusion strategies on patient outcomes in Malaysia. Data from a prospective national registry of acute coronary syndromes were used. Thirty-day all-cause mortality in 4,562 patients with ST-segment elevation myocardial infarctions was assessed by (1) cardiac care provision (specialist vs nonspecialist centers), and (2) primary reperfusion therapy (thrombolysis or primary percutaneous coronary intervention [P-PCI]). All patients were risk adjusted by Thrombolysis In Myocardial Infarction (TIMI) risk score. Thrombolytic therapy was administered to 75% of patients with ST-segment elevation myocardial infarctions (12% prehospital and 63% in-hospital fibrinolytics), 7.6% underwent P-PCI, and the remainder received conservative management. In-hospital acute reperfusion therapy was administered to 68% and 73% of patients at specialist and nonspecialist cardiac care facilities, respectively. Timely reperfusion was low, at 24% versus 31%, respectively, for in-hospital fibrinolysis and 28% for P-PCI. Specialist centers had statistically significantly higher use of evidence-based treatments. The adjusted 30-day mortality rates for in-hospital fibrinolytics and P-PCI were 7% (95% confidence interval 5% to 9%) and 7% (95% confidence interval 3% to 11%), respectively (p = 0.75). In conclusion, variation in cardiac care provision and reperfusion strategy did not adversely affect patient outcomes. However, to further improve cardiac care, increased use of evidence-based resources, improvement in the quality of P-PCI care, and reduction in door-to-reperfusion times should be achieved.

Circumflex artery related myocardial infarction: Less reperfusion therapy and large infarct size

Circumflex artery related myocardial infarction: Less reperfusion therapy and large infarct size

Blood biomarkers of insulin resistance in acute stroke patients treated with intravenous thrombolysis: Temporal profile and prognostic value

Introduction Stroke is a major cause of death and disability worldwide. Acute reperfusion therapies are aimed to reduce the amount of brain infarcted tissue, thus improving stroke outcome. Among reperfusion therapies, intravenous thrombolysis still represents the only treatment that has proven to be safe and effective in randomized clinical trials. These