Reinfarction Rate Research Articles

Impact of a nationwide public campaign on delays and outcome in Swiss patients with acute coronary syndrome

To improve the outcome in patients with acute coronary syndrome (ACS), public campaigns have been launched aimed at shortening presentation delays and allowing more efficient treatment. Their impact is uncertain. Pre-hospital delays and outcome in patients with ACS included in the Swiss National AMIS Plus registry were assessed prospectively before and after a nationwide multimedia campaign ('HELP') by the Swiss Heart Foundation in 2007. The campaign aimed at better awareness of symptoms, increasing knowledge in laymen of resuscitation and more rapid access to medical services. The primary study endpoint was the time between onset of symptoms and hospital admission. Secondary endpoints were successful out-of-hospital resuscitation, symptoms upon admission, and outcome. Between January 2005 and December 2008, 8906 ACS patients (61% ST-segment elevation myocardial infarction (STEMI), 39% non-ST-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP), mean age 65 ± 13 years, 75% males) admitted within 24 hours after onset of symptoms were enrolled. The median pre-hospital delay was reduced from 197 minutes during the pre-intervention period to 180 minutes during the post-intervention period (reduction 10% (95% confidence interval (CI) 6-14%); P < 0.001), in STEMI (reduction 10% (95% CI 5-14%); P < 0.001) and NSTEMI patients (reduction 11% (95% CI 4-17%); P = 0.001), due to pronounced effects in males (reduction 12% (95% CI 7-16%); P < 0.001) and in patients ≤75 years (reduction 12% (95% CI 8-16%); P < 0.001). Out-of-hospital resuscitation increased (odds ratio (OR) 1.26 (95% CI 1.06-1.54); P = 0.02). Overall outcome remained unchanged, however, the rate of re-infarction showed a decrease (OR 0.58 (95% CI 0.36-0.91); P = 0.021). After a nationwide educational campaign, shorter pre-hospital delays were observed, and more patients were able to be treated promptly. These results may be useful in planning future health strategies to improve management and outcome of patients with ACS, especially in female and elderly patients.

Novel Percutaneous Cardiac Assist Devices

Progress made in cardiovascular treatment over the past several decades has been impressive. Combined invasive and pharmacological treatment strategies have improved clinical outcome in patients undergoing percutaneous coronary intervention (PCI), as well as in those treated for acute myocardial infarction and decompensated heart failure. In the case of acute myocardial infarction, dramatic reductions in the progression to cardiogenic shock and the rates of reinfarction and mortality have been seen.1,–,3 In particular, in-hospital survival has improved by as much as 10 absolute percentage points, and cardiogenic shock after myocardial infarction has been cut in half.3,4 In addition, primary prevention strategies such as pharmacotherapy and aggressive risk factor modification have made significant headway in reducing the incidence of a first coronary event.4 Thus, not only do fewer patients present with acute myocardial infarction, but associated mortality has declined. The improved survival after myocardial infarction, however, has resulted in more patients living with systolic dysfunction and associated congestive heart failure.5 Heart failure, indeed, is now the major cardiovascular disease that drives hospital admissions and produces significant patient morbidity.6 This is not to say that progress has not been made in the realm of congestive heart failure, however. Both invasive (implantable devices and revascularization) and pharmacological (β-blockers and renin-angiotensin-aldosterone system antagonists) therapies have improved outcome, including quality of life, heart failure symptoms, ventricular function, and survival.7,–,10 Finally, PCI outcomes have seen dramatic improvements since the initial angioplasties performed in the late 1970s. In particular, the development of bare metal stents and, more recently, drug-coated stents, modern angioplasty balloon catheters and equipment, and safer while more effective antiplatelet therapy has improved procedural success and reduced mortality.11 Indeed, patients with higher degrees of multivessel disease, as well as concomitant …

Gender differences in clinical presentation and management of patients with acute coronary syndrome in Southwest of Saudi Arabia

Objective Gender differences in the clinical presentation and management of patients with acute coronary syndrome (ACS) have been reported in different parts of the world with contradicting results. We aimed at investigating the presence of gender bias in patients admitted with ACS to Aseer Central Hospital (ACH). Methods A retrospective cohort of all consecutive patients admitted to ACH with the diagnosis of ACS, during the period between the 1st of June 2007 and the 31st of May 2009 was studied. Data on demographic and clinical profiles, management and outcomes of ACS patients were collected and compared for both genders. Results The present study included 148 females and 397 males. Females were significantly older than males (62.9 ± 14.2 vs. 60 ± 13.4, respectively, P < 0.03), were less likely ever to have smoked (0.7% vs. 26.2%, respectively, P < 0.001), less likely to have had a history of hyperlipidemia (10.8% vs. 22.2%, respectively, P < 0.003) or family history of ischemic heart disease (10.1% vs. 18.9%, respectively, P < 0.014). Female patients presented more with atypical presentation (42.6% vs. 28.9%, respectively, P < 0.003), more with unstable angina (72.3% vs. 50.4%, respectively, P < 0.001), and less with ST-elevation myocardial infarction (18.9% vs. 40.8%, respectively, P < 0.001). Furthermore, they had significantly lower levels of hemoglobin compared to males (12.9 ± 2.3 vs. 14.5 ± 2.2 g/L, respectively, P < 0.001), and higher levels of high density lipoprotein (1.1 ± 0.4 vs. 0.98 ± 0.4 mmol/L, respectively, P < 0.008). Left ventricular ejection fraction was significantly higher in female patients compared to males (50.9 ± 14 vs. 45.8 ± 14, respectively, P < 0.003). Coronary angiography showed a higher rate of normal findings (29.3% vs. 8.9%, respectively, P < 0.001) and less severe disease (46.7% vs. 60.3%, respectively, P < 0.027) in women, however, they were less likely to undergo invasive revascularization procedures (31% vs. 42.8%, respectively, P < 0.013). No significant differences were found between both sexes regarding in-hospital mortality or re-infarction rates. Conclusion We documented gender differences in both clinical presentation as well as management of patients admitted with ACS to ACH. However, there were no significant differences between both genders regarding the clinical in-hospital outcomes. Emphasis should be made to avoid such bias in the future.

EFFICACY AND SAFETY OF GLYCOPROTEIN IIB/IIIA BLOCKER MONOFRAM IN CORONARY STENTING IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Aim. To study of efficacy and safety of glycoprotein IIb/IIIa blocker monafram in acute ST-segment elevation myocardial infarction (STEMI) patients, underwent coronary stenting. Material and methods. 220 STEMI patients were included in the trial; they were split into two groups. 109 patients of the first group were underwent coronary stenting with i/v monafram therapy. Coronary stenting without monafram therapy was performed in 111 patients of the second group. Bare metal stents were used in all patients. Deaths, stent thrombosis, individual intolerance, allergic reactions, bleeding were registered during hospitalization. Results. There were 3 (2.75%) cases of stent thrombosis in monafram group and 4 (3.6%) ones - in the control group. Good tolerance of monafram was observed in all patients. There were no allergic reactions, major and minor bleedings. Reinfarction rate was similar in both groups during 30 days observational period. Conclusions. Monafram therapy is effective and safe in acute STEMI patients underwent coronary stenting.

Molecular mechanisms of hyperglycemia and cardiovascular-related events in critically ill patients: rationale for the clinical benefits of insulin therapy

Newly recognized hyperglycemia frequently occurs with acute medical illness, especially among patients with cardiovascular disease (CVD). Hyperglycemia has been linked to increased morbidity and mortality in critically ill patients, especially when it is newly recognized. Increased rates of reinfarction, rehospitalization, major cardiovascular events, and death in CVD patients have also been found. An expanding body of literature describes the benefits of normalizing hyperglycemia with insulin therapy in hospitalized patients. This article reviews several underlying mechanisms thought to be responsible for the association between hyperglycemia and poor outcomes in critically ill patients and those with cardiovascular events, as well as the biologic rationale for the benefits of insulin therapy in these patients.

MCP-1 Gene Activation Marks Acute Kidney Injury

Monocyte chemoattractant protein 1 (MCP-1) mediates acute ischemic and toxic kidney injury, but whether this can be used as a biomarker of acute kidney injury (AKI) is unknown. We obtained kidney and urine samples from mice with intrarenal (maleate), prerenal (endotoxemia), or postrenal (ureteral obstruction) injury. We also studied the independent effects of uremia without concomitant kidney injury by performing bilateral ureteral transection in mice. Additionally, we obtained urine samples from APACHE II-matched critically ill patients with or without advancing azotemia (n = 10 in each group). We assayed selected samples for MCP-1, MCP-1 mRNA, and for an activating histone mark (H3K4m3) at urinary fragments of the MCP-1 gene and contrasted the results with those obtained for neutrophil gelatinase-associated lipocalin (NGAL), a comparator "AKI biomarker" gene. Maleate increased urinary MCP-1 protein and mRNA more than the corresponding increases in NGAL. Endotoxemia and ureteral obstruction also increased NGAL and MCP-1 gene expression. Uremia, in the absence of renal injury, induced the NGAL gene, but not MCP-1, suggesting the possibility of better specificity of MCP-1 for AKI. Clinical assessments supported the utility of MCP-1 as a biomarker (e.g., nonoverlapping concentrations of urinary MCP-1 in patients with and without AKI). Elevated levels of urinary MCP-1 mRNA and levels of H3K4m3 at the MCP-1 gene supported MCP-1 gene activation in patients with renal injury. In conclusion, these data suggest that MCP-1 has potential as a biomarker of AKI and provide "proof of concept" that urinary histone assessments provide mechanistic insight among patients with kidney disease.

Thrombus aspiration followed by direct stenting: A novel strategy of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Results of the Polish-Italian-Hungarian RAndomized ThrombEctomy Trial (PIHRATE Trial)

Previous studies with thrombectomy showed different results, mainly due to use of thrombectomy as an additional device not instead of balloon predilatation. The aim of the present study was to assess impact of aspiration thrombectomy followed by direct stenting. Patients with ST elevation myocardial infarction (STEMI) <6 hours from pain onset and occluded infarct-related artery in baseline angiography were randomized into aspiration thrombectomy followed by direct stenting (TS, n = 100) or standard balloon predilatation followed by stent implantation (n = 96). The primary end point of the study was the electrocardiographic ST-segment elevation resolution >70% (STR > 70%) 60 minutes after primary angioplasty (percutaneous coronary intervention [PCI]). Secondary end points included angiographic myocardial blush grade (MBG) after PCI, combination of STR > 70% immediately after PCI and MBG grade 3 (optimal myocardial reperfusion), Thrombolysis In Myocardial Infarction flow after PCI, angiographic complications, and in-hospital major adverse cardiac events. Aspiration thrombectomy success rate was 91% (crossing of the lesion with thrombus reduction and flow restoration). There was no significant difference in STR ≥ 70% after 60 minutes (53.7% vs 35.1%, P = .29). STR > 70% immediately after PCI (41% vs 26%, P < .05), MBG grade 3 (76% vs 58%, P < .03), and optimal myocardial reperfusion (35.1% vs 11.8%, P < .001) were more frequent in TS. There was no difference in between the groups in 6-month mortality (4% vs 3.1%, P = .74) and reinfarction rate (1% vs 3.1%, P = .29). Aspiration thrombectomy and direct stenting is safe and effective in STEMI patients with early presentation (<6 hours). The angiographic parameters of microcirculation reperfusion and ECG ST-segment resolution directly after PCI were significantly better in thrombectomy group despite the lack of the difference in ST-segment resolution 60 minutes after PCI.

Where Do We Currently Stand With Advice On Hormone Replacement Therapy For Women?

Nearly 250,000 women die each year from cardiovascular disease, making it the leading cause of death in women. The initial clinical manifestation of coronary artery disease (CAD) in women is usually 10 years later than in men on average, with the first myocardial infarction presenting 20 years later. At any age the prevalence of CAD is lower in women, but with advancing age, this gender differential diminishes. The fact that CAD prevalence is lower in women has led to the false presumption that women are protected from cardiovascular diseases. Since women live 8 to 10 years longer than men, the absolute number of deaths from cardiovascular disease (CVD) exceeds that of men. Although there has been a decline in the overall number of cardiovascular deaths, the coronary incidence has been increasing in women and decreasing in men. Contrary to belief, CAD causes far more deaths in women than does cancer (Figure 1). Consider the statistics: approximately 1 out of 3 women will die of a cardiovascular event; more than a half-million women die of CVD each year; one women dies of CVD almost each minute in the United States; and two-thirds of the women who die suddenly have no previously recognized symptoms. Advances in diagnosis and treatment of CVD appear to have translated into a survival benefit in men but not in women. The mortality due to CVD remains high in women, with no improvement in survival trends over time compared to men (Figure 2). This may be related to differences and delays in recognizing CVD in women or in treatment strategies, and to biological differences. Women with acute coronary syndrome often delay calling for professional help and present more frequently with atypical symptoms, such as abnormal pain locations, nausea, vomiting, fatigue, and dyspnea. Women not only present later from the onset of chest pain but are also sicker at the time of diagnosis. Furthermore, there appears to be a bias against heart disease in women - both patients and their caregivers/health care providers do not recognize or treat CVD in a timely manner in women. Compared to men, women are less likely to receive appropriate treatment for heart disease such as optimal control of blood pressure, use of aspirin, cholesterol-lowering medications, thrombolytics, or referrals for interventions such as balloon/ stent or bypass surgery. Women seem to be evaluated less intensively, and referrals for cardiac catheterization are 8-fold higher in men than in women. The clinical outcomes including myocardial infarction mortality, all-cause mortality, and reinfarction rates are worse in women with CVD than in men. Many risk factors contribute to CAD in women, but menopause is one of the strongest. Risk of CAD in postmenopausal women is 40 to 50% higher than in premenopausal women, and hormone replacement therapy (HRT) increases the risk. This paper discusses the myriad risk factors for CAD in women and explores the relationship between CAD and hormone replacement therapy in postmenopausal women.

E0536 Comparative effects of percutaneous coronary intervention for culprit coronary artery or together with non-culprit coronary artery in patients with multi-vessel coronary artery disease

BackgroundRapid recanalisation of the culprit lesion is the main goal of primary angioplasty for acute ST-segment elevation myocardial infarction (STEMI), but strategy for treatment of culprit and non-culprit lesions in...

Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST-segment elevation myocardial infarction: a meta-analysis

Multiple trials in patients with ST-segment elevation myocardial infarction (STEMI) compared early routine percutaneous coronary intervention (PCI) after successful fibrinolysis vs. standard therapy limiting PCI only to patients without evidence of reperfusion (rescue PCI). These trials suggest that all patients receiving fibrinolysis should receive mechanical revascularization within 24 h from initial hospitalization. However, individual trials could not demonstrate a significant reduction in 'hard' endpoints such as death and reinfarction. We performed a meta-analysis of randomized controlled trials to define the benefits of early PCI after fibrinolysis over standard therapy on clinical and safety endpoints in STEMI. We identified seven eligible trials, enrolling a total of 2961 patients. No difference was found in the incidence of death at 30 days between the two strategies. Early PCI after successful fibrinolysis reduced the rate of reinfarction (OR: 0.55, 95% CI: 0.36-0.82; P = 0.003), the combined endpoint death/reinfarction (OR: 0.65, 95% CI: 0.49-0.88; P = 0.004) and recurrent ischaemia (OR: 0.25, 95% CI: 0.13-0.49; P < 0.001) at 30-day follow-up. These advantages were achieved without a significant increase in major bleeding (OR: 0.93, 96% CI: 0.67-1.34; P = 0.70) or stroke (OR: 0.63, 95% CI: 0.31-1.26; P = 0.21). The benefits of a routine invasive strategy over standard therapy were maintained at 6-12 months, with persistent significant reduction in the endpoints reinfarction (OR: 0.64, 95% CI: 0.40-0.98; P = 0.01) and combined death/reinfarction (OR: 0.71, 95% CI: 0.52-0.97; P = 0.03). Early routine PCI after fibrinolysis in STEMI patients significantly reduced reinfarction and recurrent ischaemia at 1 month, with no significant increase in adverse bleeding events compared to standard therapy. Benefits of early PCI persist at 6-12 month follow-up.

Comparison by Meta-Analysis of Eptifibatide and Tirofiban to Abciximab in Patients With ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Adjunctive therapy with abciximab during primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI) determines a better short-term outcome compared to placebo. Tirofiban and eptifibatide represent a valid option with lower cost, but these have been less studied. The aim of the present study was to combine all randomized trials and registries to demonstrate the noninferiority of tirofiban and eptifibatide compared to abciximab in patients with STEMI treated with PPCI. We identified 6 randomized trials and 4 registries. Overall, 4,653 received small molecules and 2,696 abciximab, and the rate of combined death and nonfatal reinfarction did not differ (4.6% vs 4.5%, odds ratio 0.99, 95% confidence interval [CI] 0.78 to 1.27, p = 0.95) up to 30 days of follow-up, with an absolute difference of 0.1% (95% CI -1.06 to 0.8). Because the noninferiority limit was set at +1.5%, and because the upper point estimate (0.8%) of the 95% CI did not cross the prespecified limit, the noninferiority of the small molecules was documented. In-hospital major bleeding was also similar (8.8% vs 6.1%, odds ratio 0.92, 95% CI 0.75 to 1.13, p = 0.43). Sensitivity analysis comparing randomized trials to registries and tirofiban or eptifibatide to abciximab did not show any significant differences. In conclusion, our results documented noninferiority of "small molecules" compared to abciximab and, therefore, support their alternative use as adjunctive therapy during PPCI for patients with STEMI.

Drug-eluting versus bare-metal stent for treatment of saphenous vein grafts: a meta-analysis.

BackgroundSaphenous vein grafts develop an aggressive atherosclerotic process and the efficacy of drug eluting stents (DES) in treating saphenous vein graft (SVG) lesions has not been convincingly demonstrated. The aim of this study was to review and analyze the current literature for controlled studies comparing DES versus bare metal stents (BMS) for treatment of SVG stenoses.Methodology/Principal FindingsWe searched several scientific databases and conference proceedings up to March 15, 2010 for controlled studies comparing target vessel revascularization (TVR) between DES and BMS. Summary odds ratios (OR) for the primary endpoint TVR and secondary endpoints infarction, stent thrombosis and death were calculated using random-effect models. A total of 29 studies (3 randomized controlled trials RCT) involving 7549 (202 in RCT) patients were included. The need for target vessel revascularization in the DES group tended to be lower compared to BMS for the 3 RCT (OR 0.50 [0.24–1.00]; p = 0.051) and for observational studies (0.62 [0.49–0.79]; p<0.001). There was no significant difference in the risk for myocardial infarction in the RCT (OR 1.25 [0.22–6.99]; p = 0.250) but a lower risk for DES based on the observational studies 0.68 [0.49–0.95]; p = 0.023. The risk for stent thrombosis was found to be non-different in the RCT (OR 0.78 [0.03–21.73], p = 0.885) while it was in favor of DES in the observational studies (0.58 [0.38 – 0.84]; p<0.001). The mortality was not significantly different between DES and BMS in the RCT's (OR 2.22 [0.17 – 29.50]; p = 0.546) while the observation studies showed a decreased mortality in the DES group (0.69 [0.55–0.85]; p<0.001).ConclusionDES may decrease TVR rate in treatment of SVG stenoses. No differences in reinfarction rate, stent thrombosis or mortality was found between the DES and BMS groups in the RCT's while the observational data showed lower risk for myocardial infarction, stent thrombosis and death in the DES group. This may be a result of patient selection bias in the observational studies or represent a true finding that was not the detected in the RCT analysis due to limited statistical power.

Decision-making: Stenting in Acute Myocardial Infarction

Percutaneous coronary intervention (PCI) plays a pivotal role in the management of patients with acute myocardial infarction (AMI). Rapid revascularization of the patient with evolving AMI results in reduced rates of mortality, reinfarction and greater myocardial salvage with smaller infarct size. Since the performance of the first balloon angioplasty in 1977, remarkable advances have improved the safety and efficacy of PCI. Advances in stent technology and adjunct pharmacology have improved the outcomes for patients with AMI undergoing primary PCI. Drug-eluting stents result in a significant reduction in the clinical and angiographic rates of restenosis. Early concerns of stent thrombosis in the AMI setting have been allayed by recent results from numerous randomized clinical trials and observational studies. Reduced ischemic and hemorrhagic complications from new antithrombin and antiplatelet agents have further reduced mortality and improved event-free survival after primary PCI.

Current evidence shows no reduction in mortality or re-infarction rate with early mobilisation following myocardial infarction

Commentary on: OL Cortes, JC Villar, PJ Devereaux, et al.. Early mobilisation for patients following acute myocardiac infarction: a systematic review and meta-analysis of experimental studies. Int J Nurs Stud2009;46:1496–504.

The outcome of primary percutaneous coronary intervention for stent thrombosis causing ST-elevation myocardial infarction

There are very few scientific data about the effectiveness of primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) due to stent thrombosis (ST). The purpose of the present study is to investigate the efficacy and outcome of primary PCI for STEMI due to ST in the largest consecutive patient population with ST reported to date. A total of 2,644 consecutive STEMI patients undergoing primary PCI were retrospectively enrolled into the present study. The primary end point of this study was successful angiographic reperfusion defined as postprocedural Thrombolysis In Myocardial Infarction grade III flow. The secondary end points were cardiovascular death and reinfarction. Stent thrombosis was the cause of STEMI in 118 patients (4.4%). In patients with ST, angiographic success (postprocedural Thrombolysis In Myocardial Infarction grade III flow) was worse than in patients with de novo STEMI (76.3% vs 84.8%, P = .01). Patients with ST had significantly higher incidence of in-hospital cardiovascular mortality than patients with de novo STEMI (10.2% vs 5.3%, P = .02). In-hospital reinfarction rate was similar in both groups. In addition, long-term (mean 22 months) cardiovascular mortality and reinfarction rates were significantly higher in patients with ST compared with those without (17.4% vs 10.5%, P = .02 and 15.6% vs 9.5%, P = .03, respectively). Primary PCI for treatment of ST is less effective, and these patients are at increased risk for in-hospital and long-term mortality compared with patients undergoing primary PCI due to de novo STEMI.

Primary Angioplasty Versus Fibrinolysis in Acute Myocardial Infarction

The Danish Acute Myocardial Infarction 2 (DANAMI-2) study found that primary angioplasty (primary percutaneous coronary intervention [pPCI]) compared with fibrinolysis reduced 30-day adverse events in patients with ST-segment elevation myocardial infarction. The present study investigated whether the benefit of pPCI was maintained at a long-term follow-up. We randomly assigned 1572 patients with ST-segment elevation myocardial infarction-1129 patients at referral hospitals and 443 patients at invasive hospitals-to pPCI or fibrinolysis. Median time from randomization to arrival in the catheterization laboratory for patients admitted to referral hospitals was 67 minutes, with 96% of patients arriving in the catheterization laboratory within 120 minutes. The primary study end point was a composite of death or reinfarction. Median follow-up time was 7.8 years. For the primary end point, 8-year cumulative incidence (1-Kaplan-Meier) was 34.8% in the pPCI group and 41.3% in the fibrinolysis group (hazard ratio, 0.78; 95% confidence interval, 0.66 to 0.92). Reinfarction rates were reduced in the pPCI group (11.7% versus 18.5%; hazard ratio, 0.60; 95% confidence interval, 0.46 to 0.77). Among patients randomized at referral hospitals, pPCI reduced reinfarction (13% versus 18.5%; hazard ratio, 0.66; 95% confidence interval, 0.49 to 0.89) and mortality (26.7% versus 33.3%; hazard ratio, 0.78; 95% confidence interval, 0.63 to 0.97). The benefit of pPCI over fibrinolysis was maintained at a long-term follow-up. pPCI reduced the risk of reinfarction in the overall cohort and reduced reinfarction and mortality among patients randomized at referral hospitals. This result reinforces that pPCI should be offered to ST-segment elevation myocardial infarction patients when interhospital transport to an invasive hospital can be completed within 120 minutes.

Does on‐ versus off‐hours presentation impact in‐hospital outcomes of ST‐segment elevation myocardial infarction patients transferred to a tertiary care center?

To determine whether in-hospital outcome differs for transferred patients with ST-segment elevation myocardial infarction (STEMI) presenting during business (ON) hours vs. after (OFF) hours. Door-to-device (DTD) time is a prognostic factor in patients with STEMI and is longer during OFF hours. However, the in-hospital mortality is controversial. This registry study included 786 consecutive patients with STEMI referred for primary percutaneous coronary intervention to a tertiary care center with an on-site cardiac catheterization team 24 hrs a day/7 days (24/7) a week. ON hours were defined as weekdays 8 a.m. to 5 p.m., while OFF hours were defined as all other times, including holidays. The primary outcomes were in-hospital death, reinfarction, and length of stay (LOS). ON hours (29.5%, n = 232) and OFF hours (70.5%, n = 554) groups had similar demographic and baseline characteristics. A significantly higher proportion of patients presenting ON hours had a DTD time ≤120 min compared to OFF hours patients (32.6% vs. 22.1%, P = 0.007). The rates of in-hospital death (8.2% vs. 6%), reinfarction (0% vs. 1.1%), and mean LOS (5.7 ± 6 vs. 5.7 ± 5) were not significantly different in the ON vs. OFF hours groups, all P = nonsignificant. In a tertiary care center with an on-site cardiac catheterization team 24/7, there are no differences in in-hospital outcomes of transferred patients with STEMI during ON vs. OFF hours.

Anticoagulant Therapy for Percutaneous Coronary Intervention

Received June 2, 2009; accepted November 16, 2009. Percutaneous coronary intervention (PCI) is the most commonly performed invasive therapeutic cardiac procedure and plays an important role in the treatment of ischemic heart disease. Since the first description of coronary angioplasty in a human by Gruntzig,1 the technique, equipment, and associated pharmacotherapy have undergone substantial evolution, leading to significant improvements in periprocedural complications.2 In particular, procedural anticoagulant therapy has been the focus of numerous clinical trials, and several options are now available and supported by practice guidelines; each agent has both advantages and disadvantages, and procedural pharmacotherapy continues to be a focus of drug development. The purpose of this review is to summarize the goals of anticoagulant therapy during PCI, the pharmacokinetics and pharmacodynamics of available agents, and the clinical data surrounding each agent and to identify new agents in development. The goals of pharmacotherapy during PCI are 2-fold: (1) to mitigate the sequelae of iatrogenic plaque rupture from balloon angioplasty or stenting and (2) to reduce the risk of thrombus formation on intravascular PCI equipment. Central to these thrombotic events is thrombin (factor IIa). Iatrogenic damage to the endothelium during PCI leads to increased expression of tissue factor, activation of the coagulation cascade, and formation of activated factor Xa. This ultimately leads to the generation of thrombin, conversion of fibrinogen to fibrin, and thrombus formation.3 In addition to its effects on fibrin, thrombin also directly activates platelets, enhances platelet aggregation, and is proinflammatory.4 Because of its multiple actions in promoting thrombosis, the focus of most anticoagulant agents is thrombin inhibition. Available agents for use include unfractionated heparin (UFH), low-molecular-weight heparins (LMWH, of which enoxaparin has the largest body of clinical data), the synthetic pentasaccharides (of which fondaparinux has the largest body of clinical data), and the …

Impact of abciximab on mortality and reinfarction in patients with acute ST‐segment elevation myocardial infarction treated with primary stenting

To combine data from all randomized trials of abciximab versus placebo or open-label control in patients with STEMI treated with primary stenting to assess the short-term and long-term mortality, reinfarction, and bleeding complications. Clinical trials of adjunctive abciximab therapy in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary stenting have produced conflicting results. Formal searches of electronic databases (Medline, Cochrane) from January 1990 to April 2009 were performed. Five trials randomizing 2,937 patients (1,475 in the abciximab group, 1,462 in the placebo group) were included in the analysis. When compared with placebo, abciximab was not associated with a significant reduction in the odds of 30-day (OR 0.71, 95% CI: 0.45-1.14, P = 0.16) or long-term (OR 0.85, 95% CI: 0.48-1.50, P = 0.57) mortality. Similarly, the rate of reinfarction was not statistically different at 30 days (OR 0.59, 95% CI: 0.30-1.17, P = 0.13) or at long-term follow-up (OR 0.67; 95% CI: 0.39-1.16, P = 0.16). However, when trials with upstream use of thienopyridines were excluded, abciximab was associated with a significant reduction in the composite of death or reinfarction at 30 days (OR 0.45; 95% CI: 0.26-0.77, P = 0.004) but not at long-term follow-up (OR 0.59; 95% CI: 0.27-1.28, P = 0.18). Routine use of abciximab in patients with STEMI treated with primary stenting may reduce short-term rates of death or reinfarction in patients not administered preprocedural thienopyridine therapy, but does not appear to be beneficial in those who receive preprocedural thienopyridines.

Coronary Artery Bypass Graft Versus Drug-Eluting Stent for High-Risk Proximal Left Anterior Descending Stenosis

Determining how to treat a patient with symptomatic isolated proximal left anterior descending coronary artery disease may present a challenge. Previous randomized trials comparing percutaneous coronary intervention (PCI) with bare metal stents with minimally invasive direct coronary artery bypass surgery demonstrated significantly higher reintervention rates for stenting, with similar mortality and reinfarction rates. However, current evidence suggests that the use of drug-eluting stents may reduce the need for repeat revascularization. Also, in recent studies there were fewer periprocedural complications in patients undergoing PCI, with similar death and reinfarction rates. Moreover, the quality of life for patients who have received drug-eluting stents is similar to that of patients who have undergone minimally invasive direct coronary artery bypass surgery. Therefore, PCI with drug-eluting stents is the current treatment of choice for patients with isolated proximal left anterior descending coronary artery disease, unless they have complex lesions or repeated in-stent restenosis. In this article, the current treatment options are reviewed and outlined.