Early Coronary Angioplasty Research Articles

Routine Early Coronary Angioplasty versus Ischaemia-Guided Coronary Angioplasty after Successful Thrombolysis in Patients with Acute Anterior STEMI

Routine Early Coronary Angioplasty versus Ischaemia-Guided Coronary Angioplasty after Successful Thrombolysis in Patients with Acute Anterior STEMI

Implementation of Global Longitudinal Strain (GLS) in NON-ST Segment Elevation Myocardial Infarction in AL-Yarmook Teaching Hospital

Background: It would be advantageous to develop a noninvasive diagnostic tool that could more reliably distinguish between persons who would benefit from early coronary angioplasty and revascularization and those who would not in non-ST-segment elevation acute coronary syndrome. The LVGLS assessment is painless and may be completed quickly without putting patients through intense activities. Aim of study: To evaluate wall motion abnormality by (GLS) method in comparison with 2D echo and ECG changes. Material and method: A cross sectional study that included 60 patients who admitted to Al-Yarmouk teaching hospital due to new onset of acute coronary syndrome. Result: Mean GLS of patients was -13.61 ± 1.67, and the largest proportion of them were aged 56-60 yrs. regarding echo finding, 80% show hypokinetic motion wall abnormality. Patients with abnormal ECG changes, hypokenisia and low EF had significantly lower mean of GLS (p-value 0.0001, 0.0001, 0.004, respectively). The prediction value of GLS over EF was higher when comparing them according to presence of ECG changes and MWA. Conclusion: GLS is a powerful predictor of left ventricular function and appears to be a better metric than ejection fraction in NSTEMI patients.

Early coronary angioplasty fails to lower all-cause mortality in patients with out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis.

Out-of-hospital cardiac arrest (OHCA) is defined as the loss of functional mechanical activity of the heart in association with an absence of systemic circulation, occurring outside of a hospital. Immediate coronary angiography (CAG) with percutaneous coronary intervention is recommended for OHCA with ST-elevation. We aimed to evaluate the effect of early CAG on mortality and neurological outcomes in OHCA patients without ST-elevation. This meta-analysis and systemic review was conducted as per principles of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) group. A protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO, Ref No. = CRD42022327833). A total of 674 studies were retrieved after scanning several databases (PubMed Central, EMBASE, Medline, and Cochrane Central Register of Controlled Trials). A total of 18 studies were selected for the final analysis, including 6 randomized control trials and 12 observational studies. Statistically, there was no significant difference in primary outcome, i.e., mortality, between early and delayed CAG. In terms of the grade of neurological recovery as a secondary outcome, early and delayed CAG groups also showed no statistically significant difference. Early CAG has no survival benefits in patients with no ST elevations on ECG after OHCA.

Torsades De Pointes Complicating Acute Myocardial Infarction, Twisting the Prognosis

Introduction Torsades de pointes (TdP), a form of polymorphic ventricular tachycardia that manifests in the setting of an acquired or congenital QT interval prolongation. Polymorphic VT can occur in hyper acute phase or healing phase of an acute myocardial infarction. The presence of necrotic area caused by the infarction explains the existence of a possible circuit as well as the appearance of a re-entry arrhythmia. Aims and Objectives Our aim is to study the incidence of long Qt induced TdP in acute MI patients and its prognostic implications. We also want to analyze the impact of primary percutaneous transluminal coronary angioplasty in the management of these subset of patients. Methods In this cross-sectional observational study done from May 2021 to May 2022, We have studied 320 cases of acute MI, of which 6 were found to have TdP (1.9%). Four patients had inferior wall myocardial infarction and 2 patients had Non-ST elevation MI. Thrombolysis was done in 2 cases. Two cases underwent primary angioplasty. One case was recommended for coronary artery bypass grafting. All cases underwent appropriate electrolyte correction, besides cardioversion, as needed. Results All patients with TdP had prolonged QT interval. 50% of patients had mild hypokalemia. Two patients had complete heart block. Three patients had severe left ventricular dysfunction. Patients who underwent primary angioplasty survived. Thrombolysis had less impact on survival in Acute Mi with TdP. Conclusion Early percutaneous coronary angioplasty, combined with electrolyte correction, improves the prognosis in TdP complicating acute MI.

Why can primary angioplastics be ineffective despite the precocity of the intervention?

Early coronary revascularization is a first choice therapeutic strategy in the case of acute myocardial infarction (MI). Despite an early coronary angioplasty, however, in some cases, there is a lower efficacy of revascularization, with less favourable clinical outcome in the short and long terms. Various elements participate in the distant prognosis after primary coronary angioplasty (PCI). Among the clinical risk factors that predispose to a recurrence of ischaemic cardiovascular events are advanced age, diabetes mellitus, chronic renal failure, peripheral vascular disease, atrial fibrillation and the multiplicity of cardiovascular risk factors, which identify a higher baseline risk profile. The risk factors associated with the percutaneous interventional procedure include the presence of diffuse or complex coronary lesions, the use of small diameter stents or a suboptimal post procedural thrombolysis in MI flow. The occurrence of procedural complications, such as no-reflow, is in fact associated with an increase in the infarct area and a worse prognosis, as it favours negative ventricular remodelling. The presence of concomitant right ventricular dysfunction, the high ventricular arrhythmic burden in the acute phase, the presence of risk factors for thrombosis or intra-stent restenosis also affect the outcome after primary PCI.

P14.15: Early Preventive “Coronary Sealing” of Transmitted Coronary Artery Disease With Stent PTCA to Improve Outcomes of Heart Transplantation

Introduction: The prevalence of asymptomatic coronary atherosclerosis in the population is high, and the use of donor hearts from older individuals and “suboptimal” donors increases the likelihood of coronary artery disease (CAD) transmission to the heart recipients. Percutaneous transluminal coronary angioplasty (PTCA) with subsequent stenting improves angina symptoms but has no advantages over medical therapy in the “native heart” CAD patients. We hypothesize that early preventive coronary angioplasty would improve prognosis of the insensitive denervated donor hearts patients. Objectives: To study the impact of transmitted CAD and preventive angioplasty on the risk of death, re-transplantation, or the need for coronary revascularization in the long-term period after orthotopic heart transplantation (HT). Methods: All recipients who received the heart transplant at the Shumakov National Transplant Centre (Moscow, Russia) between January 2013 and December 2016 and survived 30 days after the surgery were included. Initial endomyocardial biopsy and coronary angiography were performed at the first week. Patients with >50% stenosis in the large branches of the coronary arteries were randomized to receive immediate PTCA or not. All-cause death, re-transplantation due to irreversible heart graft dysfunction, and the need for PTCA were used as a primary outcome composite endpoint. Results: A total of 431 HT were performed from 15.01.2013 to 29.12.2016; 389 (90.3%) patients have survived 30 days after HT; 10 (2.3%) patients who underwent repeated HT within 30 days were not included in the study. The primary coronary angiography revealed single or multiple stenoses <50% in 25 (6.6%) pts; 56 (14.9%) pts had significant >50% coronary stenosis, among them 24 random patients had the stent PTCA. During the follow-up period of 2112.1±146.0 (95% CI: 2022-2587) days, 42 (11.1%) patients died, the re-transplantation was performed in 9 (2.4%) cases, and PTCA was required in 61 (16.1%) cases. A Kaplan-Meier comparison showed a similar event-free survival rate in patients without initial changes in the coronary arteries, patients with <50% stenosis, and patients with >50% stenosis who underwent preventive PTCA, which was significantly better than had patients with >50% stenosis who did not undergo PTCA. Conclusion: The study showed that the presence of the occlusive (>50%) stenotic coronary segments in the donor’s heart has significant effect on event-free survival after HT and preventive PTCA of these segments improves the risk of death and re-transplantation while increases the likelihood of repeated coronary revascularization in the future.

Potential Mechanisms of In-stent Neointimal Atherosclerotic Plaque Formation.

Percutaneous coronary intervention has become the main revascularization strategy for coronary artery disease. Compared with early percutaneous coronary angioplasty and the extensive clinical application of bare metal stents, drug-eluting stents can significantly reduce the stenosis caused by the elastic retraction of plaque and neoatherosclerosis (NA), but there is still a high incidence of in-stent restenosis (ISR), which restricts the clinical efficacy of stent implantation. In-stent neoatherosclerosis (ISNA), defined as atherosclerotic lesions in the neointima, is one of the main causes of late stent failure. ISNA plays an important role in stent thrombosis and ISR. The rate of target lesion revascularization and in-stent thrombosis is high when NA arises. Therefore, it is of great clinical significance to explore the occurrence of NA and its development mechanism after stent implantation to prevent ISR and improve stent implantation efficacy and associated clinical prognosis. In this article, we systematically reviewed the existing clinical research on ISNA and the role of optical coherence tomography in its evaluation.

Routine Early Coronary Angioplasty versus Ischaemia-Guided Coronary Angioplasty after Successful Thrombolysis in Patients with Acute Anterior STEMI

Background: the potential benefits of routine early intervention after thrombolysis include prevention of re-infarction, recurrent ischemia, and reduction of the infarct size and mortality. Aim of the work: the purpose of this study is to compare routine early coronary angioplasty in patients with acute anterior STEMI after successful thrombolysis versus ischaemia-guided coronary angioplastyas regards the occurrence of MACCE. Study design: a total number of 100 patients with acute anterior STEMI received thrombolytic therapy and then were randomly assigned to either routine invasive strategy or ischemia based strategy based on risk stratification by stress myocardial perfusion scan done within 30 days of the onset of AMI with subsequent CA after demonstration of residual myocardial ischemia and or good viability. Results: the cumulative incidence of MACCE including recurrent ischemia, stroke, MI, HF or mortality was significantly lower in theroutine early invasive strategy. Conclusion: STEMI patients who cannot undergo timely primary PCI should receive prompt fibrinolysis followed by early routine invasive strategy.

Early Coronary Angioplasty After Thrombolysis

Over the recent years it has been clearly demonstrated that reperfusion by primary coronary angioplasty in patients with ST-elevation myocardial infarction (STEMI) is the treatment of choice. For hospitals without the capacity of performing primary angioplasty, reperfusion with on-site thrombolysis or transportation of the patient to another institution for primary percutaneous coronary intervention (PCI) within a tight timeframe are the alternative options. For the latter strategy, an organized network of centers is needed to rapidly transfer STEMI patients for primary PCI. Although transferring STEMI patients for primary PCI is superior reperfusion therapy in comparison to on-site thrombolysis, there are concerns, regarding time delays of transfer in daily practice, which is a major drawback of this therapeutic strategy as delays of >120 minutes from first medical contact to primary PCI negate the advantage of primary PCI over thrombolysis. The narrow time interval ( 3 hours to 6-12 hours in order to neutralize the thrombolysis associated complications of PCI and allow full action of antiplatelet and antithrombotic agents, had comparable efficacy in comparison to primary PCI regarding early and 1-year survival. This appears to be an effective alternative option for the treatment of STEMI patients, at least for those hospitals wherebimmediate PCI is unavailable, an issue which is particularly relevant for patients suffering a STEMI on remote

Routine early coronary angioplasty after thrombolysis in acute ST-elevation myocardial infarction: lysis is not the final step

This editorial refers to ‘Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: a meta-analysis’, by S. P. D'Souza et al. doi:10.1093/eurheartj/ehq398 Primary coronary intervention (PCI) is the preferred reperfusion therapy in patients with acute ST-elevation myocardial infarction (STEMI). However, many hospitals lack PCI facilities and few provide around-the-clock staffing for these procedures. Therefore, thrombolysis is administered to eligible patients if primary PCI cannot be performed in a timely fashion. Traditionally, the standard approach for a patient who had received thrombolytics and presented signs of reperfusion injury was to assess the risk of future cardiac adverse events before discharge. The two most important parameters used to evaluate short-term and long-term risk following myocardial infarction were left ventricular function and the extent and grade of myocardial ischaemia. Patients with spontaneous or induced severe ischaemia or left ventricular dysfunction were candidates for angiography and revascularization. Outside these circumstances, coronary arteriography was not recommended, as there was no evidence of any benefit to the patient if residual ischaemia or left ventricular dysfunction was not observed. In the late 1980s, before stents and glycoprotein IIb/IIIa inhibitors or thienopyridines began to be used, the results of routine cardiac catheterization and systematized PCI were disappointing.1 However, current interventional practice, which uses stents, thienopyridines, and IIb/IIIa inhibitors, has generated studies that again highlight the role of early routine angioplasty in the management of patients with STEMI receiving thrombolysis. The results of those studies have recently been analysed in two meta-analyses,2,3 one of which has led to this editorial.3 Adjunctive or early elective PCI is used in patients who are initially successfully reperfused with thrombolysis and who undergo early (i.e. <24 h), routine (i.e. not rescue), and, if appropriate, planned (i.e. not urgent) catheterization. This approach combines the …

Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: a meta-analysis

Prompt coronary reperfusion following acute ST-segment elevation myocardial infarction is pivotal to survival. Primary angioplasty is the gold standard in restoring reperfusion, but thrombolysis needs consideration when optimal call to balloon time is not feasible. Following lysis and with evolving pharmacoinvasive therapies, the advantage of routine, early percutaneous coronary intervention (PCI) over standard ischaemia-guided PCI remains debatable. We meta-analysed studies comparing these two interventional strategies. A MEDLINE search for randomized control studies was performed using the search terms 'coronary, thrombolysis, early or immediate stenting, and acute ST-elevation myocardial infarction'. Further, relevant studies were identified from global cardiovascular scientific sessions/congresses. Two interventional strategies were studied in 3195 patients in eight trials and meta-analysed using a random effects model. The combined endpoint of 30-day mortality, re-infarction, and ischaemia was reached in 106/1487 (7.3%) patients in the routine early PCI group and in 199/1470 (13.5%) patients in the ischaemia-guided PCI group following lysis with odds ratio (OR) 0.47 [95% confidence interval (CI), 0.32-0.68, P < 0.0001] favouring routine early PCI, driven by significant reduction in both re-infarction OR 0.62 (95% CI, 0.42-0.90, P < 0.011) and ischaemia OR 0.21 (95% CI, 0.10-0.47, P < 0.001). Thirty-day mortality or major bleeding rates between strategies were not significantly different. Where primary PCI is not feasible, our meta-analysis favours routine early PCI within 24 h of thrombolysis for acute ST-elevation myocardial infarction-a strategy that is safe and a time-target that is easily achievable. Early PCI is associated with reduced recurrence of ischaemia and re-infarction, but at no increased risk of major haemorrhage.

Routine Early Coronary Angioplasty After Thrombolysis

Over the recent years it has become abundantly clear that reperfusion by primary angioplasty in patients with ST-elevation myocardial infarction (STEMI) is the treatment of choice. For hospitals that lack facilities for percutaneous coronary intervention (PCI), on site thrombolysis remains their first option, or alternatively patients can be transferred to other institutions for PCI, if this can be accomplished within a tight time frame. For the latter strategy, an organized network of centers is needed to rapidly and safely transfer STEMI patients for primary PCI. Thus, although transferring STEMI patients for primary PCI appears to be a superior reperfusion strategy compared with on-site fibrinolysis at a no-PCI capable hospital, time delays associated with transferring patients for PCI in routine clinical practice remains a major drawback of the whole concept. The tight time interval of 90-120 min needed to take full advantage of primary PCI, probably can be extended several hours, if an initial reperfusion treatment with thrombolysis is chosen, followed by routine angioplasty in the subsequent hours. This strategy, also referred as adjunctive PCI after thrombolysis in the literature, is easily differentiated from facilitated PCI, when a thrombolytic regimen is specifically used to maximize initial reperfusion rate and not in order to `gain` time, and ischemia-driven PCI, when an intervention becomes mandatory after objective evidence of post-infarction ischemia. At least these are the convincing results from recent trials published over the last three years, such as TRANSFER-AMI, FAST-MI, GRACIA-2, WESTMI, CARESS-AMI and NORDISTEMI. When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of primary PCI. Finally, when analyzed according to the timing of PCI after thrombolysis, mortality tended to be lower with increasing time from thrombolysis when PCI was performed on a systematic basis, whereas it tended to increase with increasing time from thrombolysis when PCI was performed as a rescue procedure. Sufficient time course, probably >2-3 hours to 6-12 hours, which neutralizes the pre-hemorrhagic effect of thrombolysis and allows the antiplatelet agents to act, is the key point for a better outcome when thrombolysis is combined with early angioplasty. This appears to be a more effective and practical way to treat STEMI patients, at least for those hospitals, whereby immediate PCI is not available. Review Cardiology Department, Thriasio Hospital, Elefsina, Attica, Greece HOSPITAL CHRONICLES 2010, 5(3): 127–132

LV performance and exercise capacity in patients aged 65 years and older treated by early coronary angioplasty or conservatively for acute myocardial infarction: a one year follow-up

LV performance and exercise capacity in patients aged 65 years and older treated by early coronary angioplasty or conservatively for acute myocardial infarction: a one year follow-up

Incomplete myocardial rupture following inferior myocardial infarction: A case report

In an era of early and invasive therapeutic approaches, myocardial rupture has become an uncommon complication of myocardial infarction. While septal wall rupture most often leads to devastating haemodynamic consequences, free wall rupture is usually fatal. We report a case of a 48-year-old man in whom an incomplete myocardial rupture located in the inferior part of the interventricular septum was promptly detected during the acute phase of an inferior myocardial infarction treated by early percutaneous coronary angioplasty. A conservative rather than a surgical approach was decided with a favourable short-term outcome.

Inverse relation between diastolic blood pressure and long-term outcomes in patients undergoing pharmacoinvasive therapy for myocardial infarction: the J-shaped relation in the contemporary era of revascularisation

In the thrombolytic era, it was reported that in the presence of significant coronary stenosis, lowering diastolic blood pressure (DBP) below a critical threshold would result in a paradoxical increase in the occurrence of myocardial infarction (MI). We sought to re-evaluate this J-shaped relation in the era of pharmacoinvasive therapy. A total of 182 patients who underwent early (<1 week, mean 2.3 days) coronary angioplasty after thrombolysis were analysed. Thrombolytic agents (streptokinase in 60%, tissue plasminogen activator in 40%) were administered in an average door-to-needle time of 66 min (<=30 min in 43 [24%] patients). A thrombolysis in myocardial infarction (TIMI) 3 flow was achieved in 56% of patients after thrombolysis, and it was enhanced to 92% after angioplasty. During an average follow-up period of 26 +/-13 months, the adverse event (death, re-MI, target vessel revascularisation or stroke) rate was 21%. Older age, low systolic blood pressure and DBP, fast heart rate, high creatine kinase, hypercholesterolaemia, thrombus-laden lesion, baseline TIMI 0-2 flow were associated with higher occurrence of adverse events. After adjusting for the differing clinical and procedural factors, low DBP (odds ratio 1.10, 95% confidence interval 1.01-1.20, P = 0.041), fast heart rate (odds ratio 1.08, 95% confidence interval 1.02-1.14, P = 0.008) and anterior MI (odds ratio 18.98, 95% confidence interval 2.13-169.19, P = 0.008) were all independent predictors of long-term adverse rate occurrence. A low DBP is an independent predictor of long-term adverse event rates in patients undergoing routine early coronary angioplasty after thrombolysis. This suggests that excessive lowering of DBP may not be desirable before complete revascularisation.

Downstream administration of a high-dose tirofiban bolus in high-risk patients with unstable angina undergoing early percutaneous coronary intervention

Background The best treatment option for high-risk patients with unstable coronary syndrome is an early invasive strategy accompanied by intensive anti-platelet therapy. We tested the effect on clinical outcome of early coronary angioplasty using a high-dose bolus of tirofiban in patients with non-ST segment elevation acute coronary syndrome. Methods One hundred and forty consecutive patients with unstable coronary syndrome who underwent an immediate percutaneous coronary intervention with the administration of a high (25 μg/kg) dose bolus of tirofiban followed by an 18-h infusion of 0.15 μg kg −1 min −1 were compared with a matched control group of 162 patients treated with abciximab. The primary endpoint of the study was the 30-day incidence of major adverse cardiac events; the secondary endpoints were the incidence of major and minor bleeding. Results The time from admission to PCI was slightly shorter in the tirofiban group (3.9 ± 4.8 vs. 4.5 ± 4.4 h; P = 0.26). The 30-day rate of major adverse cardiac events was similar in the two groups (6% with tirofiban and 8.6% with abciximab: OR = 1.37, 95% CI = 0.58–3.29, P = 0.52). No major bleeding episodes were observed; the incidence of minor bleeding was 3.6% in the tirofiban group and 2.5% in the abciximab group (OR = 0.68, 95% CI = 0.18–2.59, P = 0.74). Conclusions In this preliminary study, the beneficial effect of the administration of a high-dose tirofiban bolus on 30-day clinical outcomes was similar to that of abciximab in high-risk patients with unstable angina undergoing immediate percutaneous coronary intervention. The results of this therapeutic strategy should be tested in a larger randomised study.

Early direct coronary angioplasty in survivors of out-of-hospital cardiac arrest

genic shock complicating acute myocardial infarction: the Second National Registry of Myocardial Infarction. Am Heart J 2001;141:65–72. 11. Webb JG, Sleeper LA, Buller CE, Boland J, Palazzo A, Buller E, White HD, Hochman JS. Implications of the timing of onset of cardiogenic shock after acute myocardial infarction: a report from the SHOCK Trial Registry. J Am Coll Cardiol 2000;36:1084–1090. 12. Antoniucci D, Valenti R, Santoro GM, Bolognese L, Trapani M, Moschi G, Fazzini PF. Systematic direct angioplasty and stent-supported angioplasty therapy for cardiogenic shock complicating acute myocardial infarction: in-hospital and long-term survival. J Am Coll Cardiol 1998;31:294–300. 13. Gacioch GM, Ellis SG, Lee L, Bates ER, Kirsh M, Walton JA, Topol EJ. Cardiogenic shock complicating acute myocardial infarction: the use of coronary angioplasty and the integration of the new support devices into patient management. J Am Coll Cardiol 1992;19:647–653. 14. Lee L, Erbel R, Brown TM, Laufer N, Meyer J, O’Neill WW. Multicenter registry of angioplasty therapy of cardiogenic shock: initial and long-term survival. J Am Coll Cardiol 1991;17:599–603. 15. Perez-Castellano N, Garcia E, Serrano JA, Elizaga J, Soriano J, Abetuya M, Botas J, Rubio R, de Sa EL, Lopez-Seldon JL, Delcan JL. Efficacy of invasive strategy for the management of acute myocardial infarction complicated by cardiogenic shock. Am J Cardiol 1999;83:989–993.

Elevation of two molecular forms of adrenomedullin in plasma and urine in patients with acute myocardial infarction treated with early coronary angioplasty

Elevation of two molecular forms of adrenomedullin in plasma and urine in patients with acute myocardial infarction treated with early coronary angioplasty

Elevation of two molecular forms of adrenomedullin in plasma and urine in patients with acute myocardial infarction treated with early coronary angioplasty

Adrenomedullin (AM) has vasodilatory, diuretic and natriuretic actions. Two molecular forms of AM circulate in human plasma: an active, mature form of AM (AM-m) and an intermediate, inactive, glycine-extended form of AM (AM-Gly). In the present study we investigated the pathophysiological significance of the two molecular forms of AM in plasma and urine in patients with acute myocardial infarction. We serially measured venous and arterial plasma levels and urinary excretion of AM-m, AM-Gly and total AM (Am-T; =AM-m+AM-Gly) over 2 weeks using our recently developed immunoradiometric assay in 26 consecutive patients with acute myocardial infarction and in age-matched normal controls, and studied the relationships between AM levels and clinical parameters. Plasma AM-m, AM-Gly and AM-T levels were increased on admission in patients with acute myocardial infarction compared with age-matched normal controls. Levels of AM-m, AM-Gly and AM-T in plasma reached a peak 24 h after the onset of symptoms. Plasma AM-m, AM-Gly and AM-T levels were significantly correlated with plasma levels of brain natriuretic peptide and pulmonary arterial pressure. Plasma AM-Gly levels in the vein were similar to those in the artery, whereas plasma AM-m levels were significantly lower in the artery than in the vein. Urinary excretion of AM-m, AM-Gly and AM-T was also increased on admission, and reached a peak at 12 h after the onset of symptoms. Urinary excretion of AM-m and AM-Gly was significantly correlated with urinary sodium excretion. The AM-m/AM-T ratio was significantly higher in the urine than in the vein or artery. AM-m levels were significantly correlated with AM-Gly levels in both the urine and plasma; however, there were no significant correlations between plasma and urinary AM levels. The results suggest that levels of both molecular forms of AM are increased in the urine as well as in the plasma in the acute phase of myocardial infarction. Since AM exerts potent cardiovascular and renal effects, increased concentrations of AM in plasma and urine in the acute phase of myocardial infarction may be involved in the defence mechanism against further elevations of peripheral and pulmonary vascular resistance and oliguria in acute myocardial infarction.

Effectiveness of early coronary angioplasty and abciximab for failed thrombolysis ( reteplase or alteplase) during acute myocardial infarction (results from the GUSTO-III trial)

We evaluated the effects of abciximab treatment during early angioplasty after clinically failed thrombolysis for acute myocardial infarction. In the Global Use of Strategies To Open occluded coronary arteries (GUSTO-III) trial of reteplase versus alteplase for acute infarction (n = 15,059), 392 patients underwent angioplasty a median of 3.5 hours after thrombolysis and had complete procedural data. We compared 30-day mortality and in-hospital outcomes between patients who received abciximab (n = 83) and those who did not (n = 309), and (among patients given abciximab) between those randomized to alteplase versus reteplase. Patients given abciximab had anterior infarction less often, but were more often in Killip classes III or IV. The 30-day mortality rate tended to be lower with abciximab (3.6% vs 9.7%, p = 0.076), more so after adjustment for baseline differences (p = 0.042). The composite of death, stroke, or reinfarction did not differ significantly with abciximab treatment (12% vs 14%, p = 0.7), but it occurred less often among abciximab-treated patients who had been randomized to reteplase (n = 55) versus alteplase (n = 28) (7% vs 21%, p = 0.08). Severe bleeding was increased among abciximab-treated patients (3.6% vs 1.0%, p = 0.08), despite less heparin use. No intracranial hemorrhages occurred with abciximab. The use of abciximab for early angioplasty after clinically failed thrombolysis resulted in trends toward lower 30-day mortality and increased bleeding.