Showing papers by "Elliott M. Antman published in 2002"
TL;DR: The American College of Cardiology (ACC)/AHA Task Force on Practice Guidelines regularly reviews existing guidelines to determine when an update or full revision is needed.
Abstract: The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines regularly reviews existing guidelines to determine when an update or full revision is needed. This process gives priority to areas where major changes in text, and particularly recommendations
2,537 citations
TL;DR: These guidelines represent an update of those published in 1996 and are intended for physicians who are involved in the preoperative, operative, and postoperative care of patients undergoing noncardiac surgery.
1,626 citations
TL;DR: These revised guidelines for the management of unstable angina and non–ST-segment elevation myocardial infarction were published in September 2000 and the present article describes these revisions and provides further updates in this rapidly moving field.
Abstract: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the management of unstable angina and non–ST-segment elevation myocardial infarction (UA/NSTEMI) were published in September 2000.1 Since then, a number of clinical trials and observational studies have been published or presented that, when taken together, alter significantly the recommendations made in that document. Therefore, the ACC/AHA Committee on the Management of Patients With Unstable Angina, with the concurrence of the ACC/AHA Task Force on Practice Guidelines, revised these guidelines. These revisions were prepared in December 2001, reviewed and approved, and then published on the ACC World Wide Web site (www.acc.org) and AHA World Wide Web site (www.americanheart.org) on March 15, 2002. The present article describes these revisions and provides further updates in this rapidly moving field. Minor clarifications in the wording of three recommendations that now appear differently from those that were previously published on the ACC and AHA Web sites are noted in footnotes.
The ACC/AHA classifications I, II, and III are used to summarize indications as follows:
Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.
The weight of the evidence was ranked highest (A) if the data were derived from multiple randomized clinical trials that involved large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials that involved small numbers of …
1,496 citations
TL;DR: The current update of the ACC/AHA/NASPE Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices includes several significant changes in the recommendations and in the supporting narrative portion.
1,492 citations
01 Jan 2002
TL;DR: The 10 major areas of change reflected in the update are described in a format that can be read and understood as a stand-alone document and are referred to the full-length Internet version to completely understand the context of these changes.
1,138 citations
TL;DR: The ACC/AHA guidelines for exercise testing that were published in 1997 have now been updated as mentioned in this paper and the full-text guidelines incorporating the updated material are available on the Internet (www.acc.org or www.americanheart.org).
1,015 citations
TL;DR: Troponin, CRP, and BNP each provide unique prognostic information in patients with ACS and a simple multimarker strategy that categorizes patients based on the number of elevated biomarkers at presentation allows risk stratification over a broad range of short- and long-term major cardiac events.
Abstract: Background— In patients with acute coronary syndromes (ACS), troponin I (TnI), C-reactive protein (CRP), and B-type natriuretic peptide (BNP) each predict adverse cardiac events. Little is known, however, about the utility of these biomarkers in combination. Methods and Results— Baseline measurements of TnI, CRP, and BNP were performed in 450 patients in OPUS-TIMI 16. Elevations in TnI, CRP, and BNP each were independent predictors of the composite of death, myocardial infarction (MI), or congestive heart failure (CHF). When patients were categorized on the basis of the number of elevated biomarkers at presentation, there was a near doubling of the mortality risk for each additional biomarker that was elevated (P=0.01). Similar relationships existed for the endpoints of MI, CHF, and the composite, both at 30 days and through 10 months. In a validation cohort of 1635 patients in TACTICS-TIMI 18, the number of elevated biomarkers remained a significant predictor of the composite endpoint after adjustment fo...
765 citations
TL;DR: The current update of the ACC/AHA/NASPE Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices includes several significant changes in the recommendations and in the supporting narrative portion as mentioned in this paper.
Abstract: The current update of the ACC/AHA/NASPE Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices includes several significant changes in the recommendations and in the supporting narrative portion. In this summary, we list the updated recommendations along with the respective 1998 recommendations, each one accompanied by a brief comment outlining the rationale for the changes, additions, or deletions. All new or revised recommendations are listed in the second column and appear in boldface type. References that support either the 1998 recommendations that have not changed or the new or revised recommendations are noted in parentheses at the end of each recommendation. The reader is referred to the full-text version of the guidelines posted on the American College of Cardiology (ACC), American Heart Association (AHA), and North American Society for Pacing and Electrophysiology (NASPE) World Wide Web sites for a more detailed exposition of the rationale for these changes. In addition to the recommendation changes listed here, this update includes an expanded section on the selection of pacemakers and implantable cardioverter-defibrillators (ICDs) that reflects the technical advances that have taken place since 1998. A brief expanded summary of pacemaker follow-up procedures is also new to these guidelines. For both of these …
753 citations
TL;DR: The current update of the ACC/AHA/NASPE Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices includes several significant changes in the recommendations and in the supporting narrative portion.
Abstract: The current update of the ACC/AHA/NASPE Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices includes several significant changes in the recommendations and in the supporting narrative portion. In this summary, we list the updated recommendations along with the respective
522 citations
TL;DR: This chapter discusses the development of Guidelines, further preoperative testing to Assess Coronary Risk, and management of Specific Preoperative Cardiovascular Condition.
Abstract: Table of ContentsI. IntroductionA. Development of GuidelinesB. General ApproachC. Preoperative Clinical EvaluationII. Further Preoperative Testing to Assess Coronary RiskA. Clinical MarkersB. Functional CapacityC. Surgery-Specific RiskIII. Management of Specific Preoperative Cardiovascular Condition
421 citations
TL;DR: In this paper, the authors evaluated enoxaparin with full-dose tenecteplase (TNK) and half-dose TNK plus abciximab.
Abstract: Background— ENTIRE-TIMI 23 evaluated enoxaparin with full-dose tenecteplase (TNK) and half-dose TNK plus abciximab. Methods and Results— Patients (n=483) with ST-elevation MI presenting <6 hours from symptom onset were randomized to full-dose TNK and either unfractionated heparin (UFH) (bolus 60 U/kg; infusion 12 U/kg per hour) or enoxaparin (1.0 mg/kg subcutaneously every 12 hours±initial 30 mg intravenous bolus), or half-dose TNK plus abciximab and either UFH (bolus 40 U/kg; infusion 7 U/kg per hour) or enoxaparin (0.3 to 0.75 mg/kg subcutaneously every 12 hours±initial intravenous bolus of 30 mg). With full-dose TNK and UFH, the rate of TIMI 3 flow at 60 minutes was 52% and was 48% to 51% with enoxaparin. Using combination therapy, the rate of TIMI 3 flow was 48% with UFH and 47% to 58% with enoxaparin. The rate of TIMI 3 flow among all UFH patients was 50% and was 51% among enoxaparin patients. Through 30 days, death/recurrent MI occurred in the full-dose TNK group in 15.9% of patients with UFH and 4....
TL;DR: Direct thrombin inhibitors are superior to heparin for the prevention of death or myocardial infarction in patients with acute coronary syndromes, and this information should prompt further clinical development of direct throm bin inhibitors for the management of arterial thrombosis.
TL;DR: The TIMI Risk Score is a simple clinical tool for risk assessment that may aid in the early identification of patients who should be considered for treatment with potent antiplatelet therapy.
Abstract: Aims We evaluated the TIMI Risk Score for Unstable Angina and Non-ST Elevation Myocardial Infarction for predicting clinical outcomes and the efficacy of tirofiban in non-ST elevation acute coronary syndromes.
Methods and Results Developed in TIMI 11B, the risk score is calculated as the sum of seven presenting characteristics (age ≥65 years, ≥3 cardiac risk factors, documented coronary disease, recent severe angina, ST deviation ≥0·5mm, elevated cardiac markers, prior aspirin use). The risk score was validated in the PRISM-PLUS database (n=1915) and tested for interaction with the efficacy of tirofiban+heparin vs heparin alone. The risk score revealed an increasing gradient of risk for death, myocardial infarction or recurrent ischaemia at 14 days ranging from 7·7–30·5% ( P <0·001). Dichotomized at the median, patients with a score ≥4 derived a greater relative risk reduction with tirofiban ( P (Interaction)=0·025). Among patients with normal creatine kinase myocardial bands, the risk score showed a 3·5-fold gradient of risk ( P <0·001) and identified a population that derived significant benefit from tirofiban (RR 0·73, P =0·027).
Conclusion The TIMI Risk Score is a simple clinical tool for risk assessment that may aid in the early identification of patients who should be considered for treatment with potent antiplatelet therapy.
TL;DR: The pharmacokinetic and pharmacodynamic profiles after enoxaparin administration are consistent across a broad range of patients with ACS, and creatinine clearance emerged as the most influential factor on apparent clearance, area under the curve, and anti-Xa activity.
TL;DR: Early administration of magnesium in high-risk patients with STEMI has no effect on 30-day mortality, and in current coronary care practice there is no indication for the routine administration of intravenous magnesium in patients withSTEMI.
TL;DR: Prehospital administration of rPA is a feasible approach to accelerating reperfusion in patients with STEMI and valuable time savings can be achieved in the setting of contemporary transport and door-to-drug times and may translate into an improvement in clinical outcomes.
TL;DR: Cardiac-specific troponins are useful not only because they come close to fulfilling many of the criteria for an ideal biologic marker, but also because they convey prognostic information and can help frame therapeutic decisions regarding patients with acute cardiac problems.
Abstract: After the loss of integrity of cardiac myocyte membranes, intracellular macromolecules (cardiac biologic markers) diffuse into the cardiac interstitium, lymphatics, and microvasculature; eventually, they are detected in the peripheral circulation. The release kinetics of the various cardiac biologic markers depend in part on their location in the myocyte, their molecular weight, and the route by which they are cleared from the circulation. Cardiac-specific troponins are useful not only because they come close to fulfilling many of the criteria for an ideal biologic marker, but also because they convey prognostic information and can help frame therapeutic decisions regarding patients with acute . . .
01 Jan 2002
TL;DR: This research presents a state-of-the-art virtual reality system that allows for real-time, 3D image analysis of the brain’s ability to process high-resolution 3D data.
Abstract: Raymond J. Gibbons, MD, FACC, Chair Elliott M. Antman, MD, FACC, Vice Chair Peter B. Berger, MD, FACC Hugh Calkins, MD, FACC Bernard R. Chaitman, MD, FACC Gordon A. Ewy, MD, FACC Kirsten E. Fleischmann, MD, MPH, FACC Lee A. Fleisher, MD, FACC James B. Froehlich, MD, FACC Richard J. Gusberg, MD, FACS Jeffrey A. Leppo, MD, FACC Thomas Ryan, MD, FACC Robert C. Schlant, MD, FACC William L. Winters, Jr, MD, MACC
TL;DR: Sufficiently simple to be practical at the bedside and effective for risk assessment across a spectrum of patients, the TIMI risk score may be useful in triage and treatment of patients with STEMI who are treated with reperfusion therapy.
Abstract: CONTEXT
The Thrombolysis in Myocardial Infarction (TIMI) risk score for ST-elevation myocardial infarction (STEMI) is a simple integer score for bedside risk assessment of patients with STEMI. Developed and validated in multiple clinical trials of fibrinolysis, the risk score has not been validated in a community-based population.
OBJECTIVE
To validate the TIMI risk score in a population of STEMI patients reflective of contemporary practice.
DESIGN, SETTING, AND PARTICIPANTS
The risk score was evaluated among 84 029 patients with STEMI from the National Registry of Myocardial Infarction 3 (NRMI 3), which collected data on consecutive patients with myocardial infarction (MI) from 1529 US hospitals between April 1998 and June 2000.
MAIN OUTCOME MEASURES
Ability of the TIMI risk score to correctly predict risk of death in terms of model discrimination (c statistic) and calibration (agreement of predicted and observed death rates).
RESULTS
Patients in NRMI 3 tended to be older, to be more often female, and to have a history of coronary disease more often than those in the derivation set. Forty-eight percent received reperfusion therapy. The TIMI risk score revealed a significant graded increase in mortality with rising score (range, 1.1%-30.0%; P<.001 for trend). The risk score showed strong prognostic capacity overall (c = 0.74 vs 0.78 in derivation set) and among patients receiving acute reperfusion therapy (c = 0.79). Predictive behavior of the risk score was similar between fibrinolytic-treated patients (n = 23 960; c = 0.79) and primary percutaneous coronary intervention patients (n = 15 348; c = 0.80). In contrast, among patients not receiving reperfusion therapy, the risk score underestimated death rates and offered lower discriminatory capacity (c = 0.65).
CONCLUSIONS
Sufficiently simple to be practical at the bedside and effective for risk assessment across a spectrum of patients, the TIMI risk score may be useful in triage and treatment of patients with STEMI who are treated with reperfusion therapy.
TL;DR: Findings regarding enoxaparin add to the data to be considered by clinicians when selecting an antithrombin for the acute phase of management of unstable angina/non-ST elevation myocardial infarction.
Abstract: Background Enoxaparin treatment is associated with a 20% reduction in clinical events during the acute phase of management of patients with unstable angina/non ST elevation myocardial infarction. Interest in the use of enoxaparin would be enhanced further if evidence of a durable treatment benefit over the long term could be provided.
Methods Event rates at 1 year for the composite end-point of death/non-fatal myocardial infarction/urgent revascularization and its individual components were ascertained from the TIMI 11B and ESSENCE databases.
Results There was no evidence of heterogeneity between TIMI 11B and ESSENCE in tests for interactions between treatment and trial. A significant treatment benefit of enoxaparin on the rate of death/non-fatal myocardial infarction/urgent revascularization was observed at 1 year (hazard ratio 0·88; P =0·008). The event rate was 25·8% in the unfractionated heparin group and 23·3% in the enoxaparin group, an absolute difference of 2·5%. A progressively greater treatment benefit of enoxaparin was observed as the level of patient risk at baseline increased. Treatment effects for the individual end-point elements ranged from 9–14%, favouring enoxaparin.
Conclusions The stable absolute difference in event rates of 2·5% seen at 8 days and again at 1 year favouring enoxaparin may be due to more effective control of the thrombotic process surrounding the index event. Once the pharmacological effect of enoxaparin had dissipated there was no rebound increase in events. Thus, those patients who had received enoxaparin acutely were protected from experiencing a deterioration of the original therapeutic benefit. These findings regarding enoxaparin add to the data to be considered by clinicians when selecting an antithrombin for the acute phase of management of unstable angina/non-ST elevation myocardial infarction.
TL;DR: The goal of this study was to validate the TIMI risk score in a large unselected population of patients with UAP/NSTEMI and assess its long-term predictive value.
Abstract: The 1.4 million patients admitted with unstable angina pectoris and non‐ST-elevation myocardial infarction (UAP/NSTEMI) each year are a heterogenous population with varying risks of death and recurrent cardiac events. The Thrombolysis In Myocardial Infarction (TIMI) risk score for UAP/NSTEMI was created to better stratify patients according to easily obtainable information gathered from the initial history, electrocardiogram, and cardiac markers. 1 The TIMI risk score was derived and validated in the TIMI 11B and Efficacy and Safety of Subcutaneous Enoxaparin in Non‐Q-wave Coronary Events (ESSENCE) trials and accurately predicted adverse outcomes through 14 days. It has also been applied in the Platelet Receptor Inhibition for Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) and Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS)-TIMI 18 Trials. 2,3 However, because clinical trials of UAP/ NSTEMI usually select higher risk patients (with electrocardiographic changes and/or positive cardiac markers), there has been questions whether the TIMI risk score would be valid in an unselected population of patients representative of general clinical practice. The goal of this study was to validate the TIMI risk score in a large unselected population of patients with UAP/NSTEMI and assess its long-term predictive value. ••• The details of the TIMI III Registry have been previously reported. 4 Briefly, patients admitted be
TL;DR: Thrombolysis and adjunctive/rescue PCI achieved equal rates of epicardial flow in patients with and without diabetes, however, diabetic patients had less complete ST-segment resolution, suggesting impaired microvascular flow.
TL;DR: Substantial evidence exists that patients receiving LMWH for an ACS can safely undergo cardiac catheterization and percutaneous coronary intervention, and concerns regarding the transition of these patients from the medical service to the cardiacCatheterization laboratory should not impede the upstream use of LMWH.
TL;DR: In this paper, the authors defined the prognostic value of serum myoglobin in patients with non-ST-elevation acute coronary syndromes (ACS) and established that myoglobin may be useful for the early diagnosis of myocardial infarction (MI).
TL;DR: Smokers have lower mortality after AMI than non-smokers, due in large part to lower clinical risk profiles and faster epicardial blood flow after thrombolysis, and microvascular injury does not appear to play a major role in the lower mortality risk among smokers.
Abstract: Background: Despite increased risk for coronary artery disease and acute myocardial infarction (AMI), smokers have a paradoxically lower mortality after thrombolysis for AMI than non-smokers. We determined the clinical risk profiles and coronary flow characteristics of patients in the TIMI trials according to smoking status, focusing on microvascular flow.
Methods: Among 2,573 patients in the TIMI 4, 10A, 10B and TIMI 14 trials, epicardial flow post-thrombolysis was measured using angiographic TIMI flow grades and the corrected TIMI frame count (CTFC). Microvascular flow was measured by TIMI Myocardial Perfusion Grade (TMPG) and, in TIMI 14, the percentage of ST segment resolution.
Results: Clinically, the mean age (54 vs. 62 years), the prevalence of diabetes mellitus (11% vs. 16%) and hypertension (26% vs. 40%), and the 30-day mortality (2.6% vs. 6.2%) were lower among smokers than non-smokers (all p ≤ 0.001). Angiographically, single-vessel disease (48% vs. 40%) and non-left anterior descending infarct arteries (65.4% vs. 60.8%) were more common among smokers (both p ≤ 0.01). Epicardial TIMI grade 3 flow was achieved more often in smokers than non-smokers (61% vs. 56%) and the CTFC was faster (34 vs. 37 frames/sec, both p ≤ 0.01), especially in LAD lesions. However, the frequency of normal microvascular flow (TMPG 3) was similar among smokers and non-smokers (24% vs. 29%, p = 0.16), as was the frequency of complete ST segment resolution (50% vs. 46%, p = 0.29).
Conclusions: Smokers have lower mortality after AMI than non-smokers, due in large part to lower clinical risk profiles and faster epicardial flow. Differences in tissue-level perfusion do not appear to contribute to lower mortality in smokers.
Abbreviated Abstract. After acute MI, active smokers have lower acute mortality than non-smokers that appears to be largely explained by their healthier risk profiles, less extensive coronary disease, and faster epicardial blood flow after thrombolysis. Microvascular injury does not appear to play a major role in the lower mortality risk among smokers.
TL;DR: The trend toward a lower rate of death or nonfatal MI in the bivalirudin group is consistent with a therapeutic effect of the drug and is consistentwith other trials of bivalIRudin in patients with acute coronary syndromes.
TL;DR: Treatment with enoxaparin was beneficial and well tolerated in patients with unstable angina and non-ST-segment elevation MI who underwent percutaneous coronary intervention, and exhibited a similar risk of major hemorrhage to UFH in patients who underwent PCI.
Abstract: Patients with unstable angina or non-ST-segment elevation myocardial infarction (MI) may undergo invasive revascularization procedures shortly after admission to hospital or after a brief period of stabilization. In the Thrombolysis In Myocardial Infarction (TIMI) 11B trial and Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) trial 1,326 patients underwent percutaneous coronary intervention (PCI). A total of 924 patients underwent PCI during the initial hospitalization period, and of these, 445 patients did so while receiving treatment with unfractionated heparin (UFH) or the low-molecular-weight heparin, enoxaparin. This analysis compared efficacy and clinical events in the enoxaparin and UFH groups in patients who: (1) underwent PCI while on treatment versus those who did not, and (2) underwent PCI in hospital. We also compared those who did not undergo PCI. Treatment with enoxaparin (1 mg/kg given as twice daily subcutaneous injections) was beneficial and well tolerated in patients with unstable angina and non-ST-segment elevation MI who underwent PCI. Compared with UFH, enoxaparin significantly reduced the likelihood of clinical events (death and nonfatal MI after PCI) in patients who underwent PCI after 1 year (p = 0.003 for in-hospital PCI; p = 0.005 for on-treatment PCI), with a trend toward a reduced event rate at 43 days. In addition, patients treated with enoxaparin who did not undergo PCI also showed a reduction in the risk of death, nonfatal MI, and urgent revascularization when compared with those treated with UFH (significant at 43 days, with a trend persisting at 1 year). Study limitations were that PCI was nonrandomized, the analysis was post hoc, and the sample size was relatively small. Nevertheless, in the absence of large clinical trials, this study suggests that treatment with enoxaparin was well tolerated, and exhibited a similar risk of major hemorrhage to UFH in patients who underwent PCI.
Book•
01 Jan 2002
TL;DR: 1. Decision-Making Tools Tolls for Assessment of Cardiovascular Tests and Therapies Bedside Assays in Cardiovascular Therapeutics
Abstract: 1. Decision-Making Tools Tolls for Assessment of Cardiovascular Tests and Therapies Bedside Assays in Cardiovascular Therapeutics 2. Ischemic Heart Disease Primary Prevention of Ischemic Heart Disease Pharmacologic Options for Treatment of Ischemic Heart Disease Ischemic Heart Disease: Surgical Options - A Cardiology Perspective Chronic Angina: Stable Management of Unstable Angina Acute Myocardial Infarction 3. Heart Failure Pathophysiologic and Clinical Considerations in the Treatment of Heart Failure: An Overview Principles of Pharmacologic Management of Chronic Heart Failure Ambulatory Management of Heart Failure Hospital Management of Heart Failure Cardiac Transplantation and Circulatory Support Devices 4. Arrhythmias/Conduction Disturbances Evaluation of the Patient with Disturbances of the Cardiac Rhythm Clinical Pharmacology of Antiarrhythmic Drugs Acute and Chronic Pharmacologic Management of Supraventricular Tachyarrhythmias Nonpharmacologic Treatment of Tachyarrhythmias AF - A Comprehensive Approach Malignant Ventricular Arrhythmias Implantable Devices for the Electrical Management of Heart Disease: Overview of Indications for Therapy and Selected Advances 5. Dyslipoproteinemias/Atherosclerosis Dyslipoproteinemias/Atherosclerosis: Overview of Pathology and Management Strategies Dyslipoproteinemias/Atherosclerosis: Dietary Therapy Dyslipoproteinemias/Atherosclerosis: Pharmacologic Therapy The Steps Beyond Diet and Drug Therapy for Severe Hypercholesterolemia 6. Thrombosis/Thrombolysis Antiplatelet Therapy Treatment of Venous Thromboembolism Anticoagulant and Fibrinolytic Therapy for Acute Coronary Syndromes Fibrinolytic Antithrombotic Therapy of Peripheral Vascular, Cerebrovascular, and Intracardiac Disorders 7. Hypertension Antihypertensive Therapy Lifestyle Modification in the Treatment of Hypertension Pharmacologic Treatment of Hypertension Secondary Hypertension: Endocrine Causes Secondary Hypertension: Renal Vascular Causes Treatment of Hypertension in the Patient with Cardiovascular Disease Treatment of Hypertension in Patients with Renal Disease Refractory Hypertension Hypertensive Emergencies Hypertension in Pregnancy and in Children 8. Interventional Cardiology/Cardiac Surgery Percutaneous Coronary Intervention: Indications and Patient Selection Mechanical Approaches to Percutaneous Coronary Intervention Adjunctive Pharmacology During Percutaneous Coronary Intervention High-Risk Patient Subsets for Percutaneous Coronary Interventions: Mechanisms and Management Interventional Revascularization Procedures in Acute Myocardial Infarction Interventional Procedures in the Peripheral Circulation Coronary Artery Bypass Surgery: A Surgical Perspective The Timing of Valve Surgery Surgical Therapy for Valvular Heart Disease Cost-Effectiveness of Percutaneous Intervention 9. Miscellaneous Conditions Gene Therapy for Cardiovascular Disease Pharmacologic Options for Treating Cardiovascular Disease During Pregnancy Caring for Adults with Congenital Heart Disease Treatment of Primary Pulmonary Hypertension Prevention and Treatment of Infective Endocarditis Rehabilitation of the Patient with Cardiovascular Disease Treatment of Pericardial Disease Appendices Cardiovascular Drugs Cardiovascular Devices Circulatory Support Devices
TL;DR: The influence of time from symptoms on epicardial flow and STRES reinforces the need for increased efforts to reduce treatment delays in patients with ST elevation MI and suggests phase II trials evaluating new drug combinations should consider using a randomization scheme that stratifies patients based on infarct location and time from Symptoms.
Abstract: Background When evaluating new reperfusion regimens for ST elevation MI, it is important to adjust for factors that influence the likelihood of achieving normal epicardial flow and complete ST resolution.
Methods and Results A total of 610 patients from TIMI 14 contributed to the angiographic analyses. The electrocardiographic analyses were based on 544 patients from TIMI 14 and 763 patients from InTIME-II. For each hour from onset of symptoms to initiation of pharmacological reperfusion, the odds of achieving TIMI3 flow at 90min or complete ST resolution at 60–90min decreased significantly ( P =0·03). Anterior location of infarction was associated with a reduction in the odds of achieving TIMI3 flow or complete ST resolution. The use of abciximab as part of the reperfusion regimen significantly increased the odds of TIMI3 flow ( P =0·01) and ST resolution ( P <0·001). The fibrinolytic administered (alteplase, reteplase, lanoteplase) did not influence the odds of TIMI3 flow or ST resolution after adjusting for time to treatment, infarct location, and use of abciximab.
Conclusions The influence of time from symptoms on epicardial flow and STRES reinforces the need for increased efforts to reduce treatment delays in patients with ST elevation MI. The significant benefits of abciximab with respect to facilitation of epicardial and myocardial reperfusion are evident even after adjusting for time to treatment and infarct location. To adjust for determinants of success of reperfusion regimens, phase II trials evaluating new drug combinations should consider using a randomization scheme that stratifies patients based on infarct location and time from symptoms.