Therapy For ST-segment Elevation Myocardial Infarction Research Articles

Percutaneous Coronary Intervention and 1-Year Survival in Patients Treated With Fibrinolytic Therapy for Acute ST-Elevation Myocardial Infarction

Aims To assess the predictors of 1 year mortality in patients treated with fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) and to determine whether a strategy of early percutaneous coronary intervention (PCI) improves outcome. Methods and results Consecutive patients (n ¼ 474) admitted to our unit (1998–2001) with STEMI were treated with fibrinolytic therapy. For each patient, age, gender, admission via mobile coronary care unit (MCCU), infarct location, initial systolic blood pressure and Killip class, prior history of ischaemic heart disease, hypertension, diabetes mellitus, smoking status, family history, hyperlipidaemia, and in-hospital PCI (n ¼ 154) were recorded. Mortality at 1 year was obtained from medical records (n ¼ 473). Binary logistic regression analysis was performed to determine independent predictors of 1 year mortality. Mortality in the non-PCI group was 21 vs. 7% in the PCI group. Independent predictors of 1 year mortality were age (risk ratio 1.12, 95% CI 1.08–1.15, P , 0.0001), initial SBP � 80 mmHg (risk ratio 4.34, 95% CI 1.68–11.2, P ¼ 0.002), initial Killip class � 3 (risk ratio 2.97, 95% CI 1.42–6.2, P ¼ 0.004), and lack of in-hospital PCI (risk ratio 0.39, 95% CI 0.19–0.81, P ¼ 0.012). Although the PCI group were younger (P ¼ 0.007), more likely to be admitted via the MCCU (P ¼ 0.008), with a shorter pain to needle time (P ¼ 0.04), multivariable analysis adjusted for these differences. Conclusion In-hospital PCI in patients treated with fibrinolytic therapy for STEMI is associated with a substantial reduction in 1 year mortality.

Free wall rupture in the elderly: deleterious effect of fibrinolytic therapy on the ageing heartThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

This editorial refers to ‘Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction’† by H. Bueno et al ., on page 1705 Free wall rupture (FWR) is a catastrophic mechanical complication of ST segment elevation myocardial infarction (STEMI), which occurs in up to 8% of patients and is responsible for nearly 20% of all infarction-related deaths. In fact, next to cardiogenic shock due to pump failure, FWR is the most common mechanical cause of death in STEMI patients, occurring eight to 10 times more frequently than rupture of a papillary muscle or rupture of the interventricular septum. Although the vast majority of FWRs occur within the first week following symptom onset, up to half occur within the first 24 h. FWR primarily affects the left ventricle and complicates anterior and inferior infarctions similarly. When FWR occurs, the clinical presentation is dramatic, with the rapid development of hypotension, cardiac tamponade, pulseless electromechanical activity, and death. Unfortunately, the mortality rate is >90%, and few patients can be salvaged by anything other than heroic measures, including emergent pericardiocentesis and surgical repair. Both the choice and the timing of reperfusion therapy for STEMI have been implicated in the development of FWR. Early studies of STEMI patients randomized to fibrinolytic therapy (FT) or placebo showed a paradoxical increase in early mortality in those treated with FT, which could not be explained by an increase in stroke or major bleeding; this early mortality was attributed to the development of FWR. More recently, data from studies comparing primary percutaneous coronary angioplasty (PCI) with FT showed a significantly lower risk of FWR in patients treated with primary PCI.1 Several possible mechanisms have been proposed … *Corresponding author. Tel: +1 214 645 7528; fax: +1 214 645 7501. E-mail address : james.delemos{at}utsouthwestern.edu

Percutaneous coronary intervention and 1 year survival in patients treated with fibrinolytic therapy for acute ST-elevation myocardial infarction

To assess the predictors of 1 year mortality in patients treated with fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) and to determine whether a strategy of early percutaneous coronary intervention (PCI) improves outcome. Consecutive patients (n = 474) admitted to our unit (1998-2001) with STEMI were treated with fibrinolytic therapy. For each patient, age, gender, admission via mobile coronary care unit (MCCU), infarct location, initial systolic blood pressure and Killip class, prior history of ischaemic heart disease, hypertension, diabetes mellitus, smoking status, family history, hyperlipidaemia, and in-hospital PCI (n = 154) were recorded. Mortality at 1 year was obtained from medical records (n = 473). Binary logistic regression analysis was performed to determine independent predictors of 1 year mortality. Mortality in the non-PCI group was 21 vs. 7% in the PCI group. Independent predictors of 1 year mortality were age (risk ratio 1.12, 95% CI 1.08-1.15, P < 0.0001), initial SBP < or = 80 mmHg (risk ratio 4.34, 95% CI 1.68-11.2, P = 0.002), initial Killip class > or = 3 (risk ratio 2.97, 95% CI 1.42-6.2, P = 0.004), and lack of in-hospital PCI (risk ratio 0.39, 95% CI 0.19-0.81, P = 0.012). Although the PCI group were younger (P = 0.007), more likely to be admitted via the MCCU (P = 0.008), with a shorter pain to needle time (P = 0.04), multivariable analysis adjusted for these differences. In-hospital PCI in patients treated with fibrinolytic therapy for STEMI is associated with a substantial reduction in 1 year mortality.

Association of a negative residual stenosis following rescue/adjunctive percutaneous coronary intervention with impaired myocardial perfusion and adverse outcomes among ST-segment elevation myocardial infarction patients

We hypothesized that <0% residual stenosis (RS) after rescue/adjunctive percutaneous coronary intervention (PCI) following fibrinolytic administration in ST-segment elevation myocardial infarction (STEMI) would be associated with improved outcomes. Prior studies have associated larger lumen diameters after PCI with reduced rates of restenosis and target vessel revascularization. Data were drawn from 748 patients with open epicardial arteries and with optimal luminal results (RS <20%) following rescue/adjunctive PCI after fibrinolytic administration in six STEMI trials. Patients were divided into two groups: 1) <0% RS and 2) 0% to 20% RS. A RS <0% was associated with greater gains in lumen diameter and smaller reference diameters after PCI (p < 0.001 for each), with a trend toward less frequent Thrombolysis In Myocardial Infarction flow grade (TFG) 3. A RS <0% was associated with a greater incidence of abnormal post-PCI Thrombolysis In Myocardial Infarction myocardial perfusion grades (TMPGs) (odds ratio 2.6 [1.2 to 5.9] for TMPG 0/1/2, p = 0.02), even when the analysis was restricted to patients with post-PCI TFG 3. A RS <0% following rescue/adjunctive PCI after fibrinolytic therapy for STEMI was independently associated with a reduction in the frequency of normal myocardial perfusion. Potential mechanisms of this finding include greater downstream embolization, increased stimulation of arterial stretch receptors with resultant coronary vasoconstriction, and increased vessel-wall injury after PCI. These findings suggest that additional prospective studies are needed to assess optimal RS that minimizes long-term restenosis without adverse effects.

Detecting failed thrombolysis in the accident and emergency department

The primary objective in managing a patient with ST segment elevation myocardial infarction (STEMI) is to establish reperfusion in the infarct-related artery and to maintain it. Two approaches to coronary reperfusion are used in the UK – primary angioplasty and intravenous thrombolysis. Primary angioplasty is the gold standard approach to managing STEMI, but in the UK (due to financial, resource and personnel limitations) this is not the first-line treatment. Thrombolytic therapy remains the most widely used approach and the benefits of such an approach are irrefutable; thrombolysis saves lives, reduces infarct size and limits left ventricular dysfunction. However, data from the thrombolytic trials also suggest that 30–40% of patients fail to reperfuse with standard thrombolytic therapy. Similar data demonstrates that patients who do not sustain adequate perfusion in the infarct-related artery have a poor prognosis and increased mortality rates. As long as thrombolysis remains the standard therapy for STEMI, it is important that patients in whom the treatment has been unsuccessful are swiftly recognised and appropriate interventions instituted. The criteria to assess successful reperfusion of the infarct-related artery need to be simple to apply, easy to interpret and non-invasive. This article will discuss the most useful criteria to make such a diagnosis and suggest approaches to enable recognition of ‘failed thrombolysis’ in the accident and emergency department. The current views on managing failed thrombolysis will conclude the article.