Thrombolysis In Myocardial Infarction Classification Research Articles

Rationale and design for the randomized placebo-controlled double-blind trial studying the effect of single antiplatelet therapy (clopidogrel) versus dual antiplatelet therapy (clopidogrel/acetylsalicylic acid) on the occurrence of atherothrombotic events following lower extremity peripheral transluminal angioplasty (CLEAR-PATH)

RationaleAntiplatelet therapy (APT) is the standard of care after endovascular revascularization (EVR) in patients with peripheral artery disease (PAD). APT aims to prevent both major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nonetheless, the rates of MACE and MALE after EVR remain high. In coronary artery and cerebrovascular disease, dual APT (DAPT)compared to acetylsalicylic acid alone has proven to reduce MACE without increasing the risk of major bleeding when applied for a restricted number of weeks. However, within the PAD population, insufficient data are available to understand the potential attributable effect of DAPT over single APT (SAPT). Therefore, prospective randomized studies in targeted study populations are warranted. Trial designCLEAR-PATH is a Dutch multicenter, double-blind, placebo-controlled, randomized trial comparing SAPT (clopidogrel 75mg plus placebo) with DAPT (clopidogrel 75mg plus acetylsalicylic acid 80mg) in patients with PAD undergoing EVR. CLEAR-PATH includes a time-to-event analysis with a follow-up of one year. The primary composite efficacy endpoint consists of all-cause mortality, nonfatal stroke, nonfatal myocardial infarction, severe limb ischemia, (indication for) re-intervention due to any symptomatic restenosis, re-occlusion, or due to acute limb ischemia, and major amputation. The primary safety endpoint contains major bleeding following the Thrombolysis In Myocardial Infarction classification. The enrolment started in August 2022. In total 450 primary efficacy outcome events are required which expectedly amounts to 1696 subjects. Recruitment will take approximately 36 months. ConclusionCLEAR-PATH will assess the efficacy and safety of DAPT compared to SAPT following EVR in PAD patients.

Monocyte to High-Density Lipoprotein Ratio Predicts Contrast-Induced Nephropathy in Patients With Acute Coronary Syndrome.

Contrast-induced nephropathy (CIN) is associated with worse prognosis in patients with acute coronary syndrome (ACS). Early identification and intervention for patients with a high risk of CIN are very important to improve clinical outcomes. Inflammation plays important role in the development of CIN in the setting of ACS. The monocyte to high-density lipoprotein ratio (MHR) is a novel inflammatory marker. Bleeding is also associated with worse prognosis in such patients. We aimed to investigate whether the preprocedural MHR had a predictive role for CIN development in such patients. In addition, using the thrombolysis in myocardial infarction classification, we aimed to assess whether there was any relationship between bleeding and CIN. A total of 647 patients (496 males; age: 63.3 ± 12.7 years) with ACS who underwent percutaneous coronary intervention (PCI) were included in the study. Seventy patients (10.8%) had developed CIN. Age, diabetes mellitus, contrast volume, estimated glomerular filtration rate, and MHR were independent predictors for CIN. Preprocedural MHR may be used as a simple marker of CIN. It may help with the early identification of patients with ACS who underwent PCI who are at high risk of CIN thus allowing the planning of protective measures.

Prognostic Value of Total Bilirubin in Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Coronary Intervention

Previous studies have shown that the serum total bilirubin (TB) concentration was inversely related with stable coronary artery disease, diabetes mellitus, hypertension, and metabolic syndromes. The relation between TB levels and in-hospital and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is not known. Data from 1,624 consecutive patients with STEMI who underwent primary PCI were evaluated. TB was measured after primary PCI, and the study population was divided into tertiles. The high TB group (n=450) was defined as a value in the upper third tertile (>0.9 mg/dl) and the low TB group (n= 1,174) as any value in the lower 2 tertiles (≤0.9 mg/dl). The in-hospital mortality rate was significantly greater in the high TB group than in the low TB group (4% vs 1.5%, p= 0.003). In the multivariate analyses, a significant association was noted between high TB levels and the adjusted risk of in-hospital cardiovascular mortality (odds ratio 3.24, 95% confidence interval 1.27 to 8.27, p= 0.014). In the receiver operating characteristic curve analysis, TB >0.90 mg/dl was identified as an effective cutpoint in patients with STEMI for in-hospital cardiovascular mortality (area under the curve 0.66, 95% confidence interval 0.55 to 0.76, p= 0.001). The mean follow-up period was 26.2 months. No differences wereseen in the long-term mortality rates between the 2 groups. In conclusion, high TBisindependently associated with in-hospital adverse outcomes in patients with STEMIwhoundergo primary PCI. However, no association was found with long-term mortality.

THE EFFECT OF ATROVASTATIN ON THE QRS DURATION IN THE PATIENTS WITH ACUTE ANTERIOR ST ELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY ANGIOPLASTY

ObjectivesTo evaluate the value of intensive atorvastatin treatment on changes of QRS duration and ventricular arrhythmia in the patients with acute anterior ST elevation myocardial infarction undergoing primary Angioplasty.MethodsFrom December...

Suboptimal coronary blood flow after primary percutaneous coronary intervention for acute myocardial infarction

The aim of the present study is to investigate incidence, predictors, and long-term outcomes of suboptimal coronary flow after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in a large population. A total of 2056 consecutive patients with STEMI (mean age 56.2±11.7 years, 1738 men, 318 women) undergoing primary PCI were retrospectively enrolled in the present study. Patients were grouped as optimal [thrombolysis in myocardial infarction (TIMI) 3 flow, n=1939] and suboptimal (TIMI≤2 flow, n=117) according to the TIMI classification in the infarct-related artery at final coronary angiography after primary PCI, and were followed for in-hospital and long-term outcomes for a mean period of 1.9±1.3 years (median of 22 months). Suboptimal coronary flow was observed in 5.7% (n=117) of the patients. Four variables, selected from the multivariate analysis, were weighted proportionally to their respective odds ratio for suboptimal coronary flow [predilatation before stenting (three points), Killip class 2/3 (two points), glomerular filtration rate<60 ml/min/1.73 m (two points), and anterior myocardial infarction (one point)]. Two strata of risk were defined (low risk, score 0-3; and high risk, score 4-8) and had a strong association with suboptimal coronary flow, and in-hospital and long-term cardiovascular mortalities. The suboptimal group had a higher prevalence of in-hospital mortality compared with the optimal group (22.2 vs. 1.2%, respectively, P<0.001). Long-term cardiovascular mortality was four-fold more in the suboptimal group than the optimal group (15.9 vs 3.7%, respectively, P<0.001). Suboptimal coronary flow after primary PCI in STEMI is strongly related with increased in-hospital and long-term cardiovascular mortalities. Predilatation before stenting is the most powerful predictor of suboptimal coronary flow.

Combination of the Killip and TIMI Classifications for Early Risk Stratification of Patients with Acute ST Elevation Myocardial Infarction

Objective: The Killip classification and the Thrombolysis in Myocardial Infarction (TIMI) score have been proven to be useful tools for the early risk stratification of patients with acute myocardial infarction (MI). The Killip classification is simpler and less time consuming compared to the TIMI score. We sought to evaluate the added value of applying the TIMI score to patients prestratified with the Killip classification. Methods: A total of 1,773 consecutive acute MI patients were hospitalized in 25 coronary care units operating in Israel, and were followed up to 1 year. Results: Higher Killip class was associated with increased 1-year mortality: 6, 24, 42 and 60% in Killip 1–4, respectively. Applying the TIMI score to Killip 1 patients resulted in further stratifying the patients to low-, medium- and high-risk patient groups with 1, 8 and 19% 1-year mortality rates. Conclusions: The Killip classification is a useful tool for early risk stratification of acute MI patients. Applying the TIMI score to patients classified as Killip 1 further stratified them into low-, medium- and high-risk subgroups significantly improving stratification by the Killip classification alone.

STEMI Patients—The More You Bleed, the More You Die: A Comparison Between Classifications

In patients with acute coronary syndromes, an increase in hemorrhagic complications has been observed, and bleeding is now the most frequent noncardiac complication in these patients. Clinical trials and registries have used different scales to classify the severity of bleeding; so far, none of them has been developed for ST-segment elevation myocardial infarction (STEMI) patients in the era of primary percutaneous coronary intervention. We analyzed data from our Intensive Cardiac Care Florence STEMI Registry, comprising 991 STEMI patients consecutively admitted to our intensive cardiac care unit after mechanical revascularization, to assess the clinical impact of both Thrombolysis In Myocardial Infarction (TIMI) and Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) classifications in identifying patients with major bleeding at higher risk for in-hospital mortality. Major bleeding events occurred in 8.9% of patients (88/991) in the TIMI classification and in 17.2% of patients (170/991) in the ACUITY classification. Among patients with major bleeding classified according to ACUITY, 82 patients did not meet the TIMI criteria for major bleeding. These patients represent the so-called gray zone, where no transfusion was performed and only 1 patient died. In STEMI patients who undergo primary percutaneous coronary intervention and receive dual antiplatelet therapy, TIMI is more capable than ACUITY in identifying patients with major bleeding at higher risk for early mortality. The presence of renal failure represents an independent predictor for major bleeding.

P-012 Solitaire FR in acute ischemic stroke: preliminary experience in a consecutive series of 21 cases

Background and purposePrompt recanalization of occluded brain arteries in patient victims of acute ischemic stroke (AIS) is associated with a better clinical outcome. Several trials have assessed the efficacy and...

A pilot, prospective evaluation of a direct thrombin inhibitor, bivalirudin (Angiomax), in patients undergoing lower extremity bypass

Replacing heparin with bivalirudin has been beneficial in patients undergoing coronary intervention and coronary artery bypass. The use of this alternative anticoagulant during peripheral bypass operations has not been studied. Concerns over distal thrombosis using this direct thrombin inhibitor (DTI) prompted a single-arm, open-label, pilot prospective trial of bivalirudin in patients undergoing lower extremity bypass to assess perioperative safety and efficacy. Between 2006 and 2007, 18 patients met criteria for enrollment and underwent primary lower extremity bypass using bivalirudin. All patients had severe symptomatic atherosclerotic disease requiring lower extremity bypass. Bivalirudin at a bolus dose of 0.75 mg/kg and continuous infusion of 1.75 mg/kg/hr was used as the sole anticoagulant. Patients (mean age, 67 years) underwent femoral-popliteal (n = 14) or femoral-tibial (n = 4) bypass preferentially using saphenous vein (83%). Mean operative time was 261 minutes, with bivalirudin infusion time of 95 +/- 26 minutes (mean +/- standard deviation). Reliable anticoagulation was achieved with weight-based dosing with activated clotting time values at baseline (systemic) of 131 +/- 92 seconds, during infusion (systemic) of 347 +/- 36 seconds, and from the distal vasculature (limb) of 345 +/- 66 seconds. Distal limb bivalirudin levels were stable at 9755 +/- 3860 ng/mL during clamp occlusion. Mean estimated blood loss was 332 +/- 191 mL with four patients (22%) requiring blood products. One patient required revision of the proximal anastomosis during the initial hospitalization. At 30 days, all bypass operations were patent with improvement of mean ankle-brachial index from 0.57 to 0.81. There were no deaths, myocardial infarctions, or amputations in the 30-day postoperative period. Based on the Thrombolysis in Myocardial Infarction classification for bleeding, one patient had major bleeding (>2 units of packed red blood cells), and three patients had minor bleeding within the first 30 days. Bivalirudin is a safe and effective anticoagulant for lower extremity bypass operations. Thrombosis beyond the distal clamp was not seen. A comparative trial to standard anticoagulation is warranted.

Utilization of Distal Embolic Protection in Saphenous Vein Graft Interventions (An Analysis of 19,546 Patients in the American College of Cardiology–National Cardiovascular Data Registry)

In clinical trials, the use of a distal embolic protection device (EPD) during saphenous vein graft (SVG) percutaneous intervention (PCI) decreases the incidence of major adverse events. However, the frequency of EPD use during SVG PCI in clinical practice is unknown. We evaluated 19,546 SVG PCI procedures in the American College of Cardiology-National Cardiovascular Data Registry from January 1, 2004, through March 30, 2006. EPD use was the primary outcome. Univariate and multivariable analyses were used to assess for characteristics associated with EPD use and to determine the association between EPD use and 2 outcomes: no-reflow and in-hospital mortality. EPDs were used in 22% of patients who underwent SVG PCI. Characteristics independently associated with EPD use were age (odds ratio [OR] 1.04, p = 0.03), male gender (OR 1.12, p = 0.02), older grafts (p <0.001 for the group), longer lesions (OR 1.16, p <0.001), and American College of Cardiology/American Heart Association class C lesions (OR 1.41, p <0.001). Patients were less likely to receive an EPD if they had class <3 grade flow according to Thrombolysis in Myocardial Infarction classification (p <0.001) or previously treated lesions (OR 0.55, p <0.001). There was a weak correlation between annual hospital PCI volume and EPD use (r = 0.2, p <0.001). Nineteen percent of centers did not use EPDs and 41% used them in <10% of cases. EPD use was independently associated with a lower incidence of no-reflow (OR 0.68, p = 0.032), but not in-hospital mortality (1.0% vs 0.9%, p = NS). In conclusion, in current practice, EPDs are used in <25% of SVG PCI procedures.