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Showing papers by "Elliott M. Antman published in 1996"


Journal ArticleDOI
TL;DR: In patients with acute coronary syndromes, cardiac troponin I levels provide useful prognostic information and permit the early identification of patients with an increased risk of death.
Abstract: Background In patients with acute coronary syndromes, it is desirable to identify a sensitive serum marker that is closely related to the degree of myocardial damage, provides prognostic information, and can be measured rapidly. We studied the prognostic value of cardiac troponin I levels in patients with unstable angina or non–Q-wave myocardial infarction. Methods In a multicenter study, blood specimens from 1404 symptomatic patients were analyzed for cardiac troponin I, a serum marker not detected in the blood of healthy persons. The relation between mortality at 42 days and the level of cardiac troponin I in the specimen obtained on enrollment was determined both before and after adjustment for base-line characteristics. Results The mortality rate at 42 days was significantly higher in the 573 patients with cardiac troponin I levels of at least 0.4 ng per milliliter (21 deaths, or 3.7 percent) than in the 831 patients with cardiac troponin I levels below 0.4 ng per milliliter (8 deaths, or 1.0 percent;...

1,673 citations



Journal ArticleDOI
TL;DR: The American College of Cardiology and the American Heart Association request that the following format be used when citing this document: Ryan TJ, Antman EM, Brooks NH, Califf RM, Hillis LD, Hiratzka LF, Rapaport E, Riegel B, Russell RO, Smith EE III, Weaver WD.

1,325 citations


Journal ArticleDOI
TL;DR: Hemarin and hirudin have an equal effect as adjunctive therapy to TPA and streptokinase in preventing unsatisfactory outcome in patients with acute myocardial infarction.
Abstract: Background The TIMI 9 trial evaluated whether the direct antithrombin hirudin is more effective than an indirect-acting antithrombin, heparin, as adjunctive therapy for thrombolysis in myocardial infarction. Methods and Results Patients (n=3002) with acute myocardial infarction were treated with aspirin and either accelerated-dose tissue plasminogen activator (TPA) or streptokinase. They were randomized within 12 hours of symptoms to receive either intravenous heparin (5000 U bolus followed by infusion of 1000 U/h) or hirudin (0.1 mg/kg bolus followed by infusion of 0.1 mg/kg per hour). The infusions of both antithrombins were titrated to a target activated partial thromboplastin time (aPTT) of 55 to 85 seconds and were administered for 96 hours. Patients randomized to hirudin were significantly more likely to have an aPTT measurement in the target range (P<.0001). The primary end point (death, recurrent nonfatal myocardial infarction, or development of severe congestive heart failure or cardiogenic shock...

495 citations


Journal ArticleDOI
TL;DR: These guidelines are intended for physicians, nurses, and allied healthcare personnel who care for patients with suspected or established acute myocardial infarction and promote rapid identification and treatment of patients with acute MI.
Abstract: Executive Summary andListing of Recommendations These guidelines are intended for physicians, nurses, and allied healthcare personnel who care for patients with suspected or established acute myocardial infarction (MI) These guidelines have been officially endorsed by the American Society of Echocardiography, the American College of Emergency Physicians, and the American Association of Critical-Care Nurses This executive summary and listing of recommendations appears in the November 1, 1996, issue of Circulation The guidelines in their entirety, including the ACC/AHA Class I, II, and III recommendations, are published in the November 1996 issue of the Journal of the American College of Cardiology Beginning with these guidelines, the full text of ACC/AHA guidelines will be published in one journal and the executive summary and listing of recommendations in the other Reprints of both the full text and the executive summary with its listing of recommendations are available from both organizations Each year 900 000 people in the United States experience acute MI Of these, roughly 225 000 die, including 125 000 who die “in the field” before obtaining medical care Most of these deaths are arrhythmic in etiology Because early reperfusion treatment of patients with acute MI improves left ventricular (LV) systolic function and survival, every effort must be made to minimize prehospital delay Indeed, efforts are ongoing to promote rapid identification and treatment of patients with acute MI, including (1) patient education about the symptoms of acute MI and appropriate actions to take and (2) prompt initial care of the patient by the community emergency medical system In treating the patient with chest pain, emergency medical system personnel must act with a sense of urgency When the patient with suspected acute MI reaches the emergency department (ED), evaluation and initial management should take place promptly, because the benefit of reperfusion therapy is greatest if therapy …

370 citations


Journal ArticleDOI
TL;DR: Use of lifesaving therapies for eligible patients with AMI is higher than previously reported, particularly for aspirin and thrombolytic use in nonelderly patients and increased adherence to AMI treatment guidelines is required for elderly patients and women.
Abstract: Background: Evidence-based guidelines for the treatment of patients with acute myocardial infarction (AMI) have been published and disseminated by the American College of Cardiology and the American Heart Association. Few studies have examined the rates of adherence to these guidelines in eligible populations and the influence of age and gender on highly effective AMI treatments in community hospital settings. Methods: Medical records of 2409 individuals admitted to 37 Minnesota hospitals between October 1992 and July 1993 for AMI, suspected AMI, or rule-out AMI, and meeting electrocardiographic, laboratory, and clinical criteria suggestive of AMI were reviewed to determine the proportion of eligible patients who received thrombolytic, β-blocker, aspirin, and lidocaine hydrochloride therapy. The effects of patient age, gender, and hospital teaching status on the use of these treatments were estimated using logistic regression models. Results: Eligibility for treatment ranged from 68% (n=1627) for aspirin therapy, 38% (n=906) for lidocaine therapy, and 30% (n=734) for thrombolytic therapy to 19% (n=447) for β-blocker therapy. Seventy-two percent of patients eligible to receive a thrombolytic agent received this therapy; 53% received β-blockers; 81% received aspirin; and 88% received lidocaine. Among patients ineligible for lidocaine therapy (n=1503), 20% received this agent. Use of study drugs was lower among eligible elderly patients, especially those older than 74 years (thrombolytic agent: odds ratio, 0.2; 95% confidence interval, 0.1 to 0.4; aspirin: odds ratio, 0.4, 95% confidence interval, 0.3 to 0.6;β-blocker: odds ratio, 0.4; 95% confidence interval, 0.2 to 0.8). Female gender was associated with lower levels of aspirin use among eligible patients (odds ratio, 0.7; 95% confidence interval, 0.6 to 0.9); and there was a trend toward lower levels of β-blocker and thrombolytic use among eligible women. Conclusions: Use of lifesaving therapies for eligible patients with AMI is higher than previously reported, particularly for aspirin and thrombolytic use in nonelderly patients. Lidocaine is still used inappropriately in a substantial proportion of patients with AMI. Increased adherence to AMI treatment guidelines is required for elderly patients and women. (Arch Intern Med. 1996;156:799-805)

297 citations


Journal ArticleDOI
TL;DR: These simulated meta-analyses demonstrate the main point, which is that the time of first significance, however parameterized, is itself a random variable with error variance.

81 citations


Journal ArticleDOI
TL;DR: Despite changes in the profile of patients undergoing CABG, the incidence of PMI in this tertiary center is comparable with that found in earlier series, probably because of improvements in surgical techniques and postoperative care.

68 citations


Journal ArticleDOI
TL;DR: Although the ISIS-4 study enrolled more than 58,000 patients, no reduction in mortality was seen, probably as a result of a low control group mortality and relatively late administration of the magnesium.

42 citations


Journal ArticleDOI
TL;DR: The physicians of patients with psychiatric disorder were more likely to ascribe the palpitations to anxiety or depression, and ordered fewer laboratory tests on them, but few patients who had not already been in psychiatric treatment were referred or started on psychotropic medication.
Abstract: Background: Psychiatric disorder is underdiagnosed in primary care practice, often because it is somatized and the patient reports only physical symptoms. Palpitations are among the symptoms that often are somatized. Methods: We studied prospectively 125 consecutive medical outpatients referred for ambulatory electrocardiographic monitoring to evaluate a chief complaint of palpitations. They completed an in-person research interview at the time of monitoring and a telephone follow-up interview 3 months later. The referring physicians completed questionnaires about their patients before receiving the results of the monitoring and again 3 months later. Results: Forty-three patients had clinically significant cardiac arrhythmias. Twenty-four (29%) of the remaining 82 patients had a current psychiatric disorder, and 20 of these patients (83%) had major depression or panic disorder. These patients were significantly younger and more disabled, somatized more, and had more hypochondriacal concerns about their health than did patients who had no psychiatric disorder. Their palpitations were more likely to last longer than 15 minutes, were accompanied by more ancillary symptoms, and were described as more intense. At 3-month follow-up, about 90% of the patients in both groups continued to experience palpitations. Symptoms of somatization, hypochondriacal concerns, and impairment of intermediate activities had improved in both groups, but remained higher in patients with psychiatric disorder than in patients without psychiatric disorder. During the follow-up interval, patients with psychiatric disorder had more emergency department visits. The physicians of patients with psychiatric disorder were more likely to ascribe the palpitations to anxiety or depression, and ordered fewer laboratory tests on them, but few patients who had not already been in psychiatric treatment were referred or started on psychotropic medication. Conclusions: Physicians are aware of a psychiatric component to the clinical presentation of palpitation, but this observation does not result in psychiatric treatment or referral in most cases. ( Arch Intern Med. 1996;156:1102-1108 )

42 citations


Journal ArticleDOI
TL;DR: This paper aims to demonstrate the efforts towards in-situ applicability of EMMARM, as to provide real-time information about coronary heart disease and stroke progression in patients with a history of these conditions.
Abstract: ~ Cardiovascular Division, Brigham and Women's Hospital Boston, MA; 2School of Public Health, University of North Carolina, Chapel Hill, NC; 3Division of Clinical Care Research, New England Medical Center, Boston, MA; 4Division of Cllnical Epidemiology, Brigham and Women's Hospital Boston, MA; S Channing Laboratory, Harvard Medical School Boston, MA; 6Department of Statistics, Harvard University, Cambridge, MA, USA

Journal ArticleDOI
TL;DR: In experimental studies of coronary thrombosis, hirudin was superior to heparin in facilitating thrombolysis with both tPA and streptokinase and was more effective than hepar in preventing thrombus deposition in animal models of deep arterial injury 141.
Abstract: Trials and tribulations of thrombin inhibition Thrombin is a central component in the molecular and cellular response to plaque rupture and therefore pertinent to the entire spectrum of acute coronary syndromes. This serine protease not only promotes the deposition of fibrin strands and further activation of the coagulation cascade, but is also a potent stimulus for platelet activation, induction of adhesion molecules by neutrophils and monocytes, and proliferation of vascular smooth muscle cells. The current regimen of combined antithrombin and antiplatelet therapy with heparin and aspirin, respectively, across the spectrum of acute coronary syndromes is based on the pivotal role played by thrombin as well as activated platelets (to whose activation thrombin also contributes). However, this is not an ideal regimen. Aspirin is a relatively weak antiplatelet agent and the promise of more potent agents is being fulfilled by the platelet glycoprotein Ilbllla receptor inhibitors. Heparin also leaves much to be desired. It is an indirectly acting drug that catalyzes the inactivation of fluid phase thrombin by antithrombin III, but is unable to inhibit clot-bound thrombin, which therefore remains enzymatically active. In addition to this deficiency, heparin has several other theoretical disadvantages including inhibition by platelet factor IV and marked heterogeneity of its pharmaco-kinetic and pharmacodynamic properties. Considerable effort has been expended in identifying a safe and effective antithrombin that can inhibit both fluid phase and clot-bound thrombin. The medicinal leech, hirudo medicinalis, is the source of hirudin, a 65 amino acid compound that binds directly in a 1:1 fashion via its carboxy terminus to the substrate recognition site of thrombin and via its amino terminus to the catalytic centre of thrombin. Nonsulfated forms of hirudin have been produced by recombinant technology by Ciba-Geigy (CGP 39393 also referred to as REVASC® or desi-rudin) and Hocchst Behringwerke (HBW 023) that are nearly identical in structure and activity to the naturally occurring compound 1 ' 1. In experimental studies of coronary thrombosis, hirudin was superior to heparin in facilitating thrombolysis with both tPA and streptokinase' 2 ' 31. Additionally, hirudin was more effective than heparin in preventing thrombus deposition in animal models of deep arterial injury 141. Pilot studies of patients with stable angina, unstable angina, and acute MI consistently observed that hirudin was more likely than heparin to maintain a stable aPTT in the target range, thus potentially avoiding the periods of inadequate and excessive anticoagulation frequently seen with heparin. Angio-graphic …

Journal ArticleDOI
TL;DR: Two major treatment strategies have emerged: suppression of recurrences versus control of ventricular rate and anticoagulation to reduce the risk of stroke in patients with atrial fibrillation as mentioned in this paper.
Abstract: Management of atrial fibrillation is a common and complex clinical problem. Two major treatment strategies have emerged: suppression of recurrences versus control of ventricular rate and anticoagulation to reduce the risk of stroke. Maintaining sinus rhythm offers the hemodynamic benefits of improving ventricular performance and exercise capacity but may expose the patient to the risk of proarrhythmia/sudden death and drug-related morbidity. Controlling ventricular rate helps decrease symptomatic palpitations and improve exercise capacity but necessitates long-term anticoagulation (which may also be needed despite the use of antiarrhythmics to suppress recurrences of atrial fibrillation) with some risk of bleeding. Randomized trials are now needed to define the relative benefits of these 2 treatment strategies. Such trials should be designed to provide information on the impact of the 2 approaches on symptoms, exercise capacity, quality of life, and mortality rate in patients with atrial fibrillation.