Showing papers by "Elliott M. Antman published in 2004"
TL;DR: Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists as discussed by the authors, and the purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients
Abstract: Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists.[1–3][1][][2][][3] The purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients
8,352 citations
Journal Article•
TL;DR: Elliott M. Antman,MD, FACC, FAHA, Chair; Daniel T. Anbe, MD, F ACC,FAHA; Paul Wayne Armstrong, MD; Eric R. Bates; Lee A. Green; Mary Hand; Judith S. Kushner; and Sidney C. Sloan.
7,134 citations
TL;DR: This document was approved by the American College of Cardiology Foundation Board of Trustees on May 7, 2004 and by theAmerican Heart Association Science Advisory and Coordinating Committee on May 5, 2004.
1,846 citations
TL;DR: The major areas of change reflected in the update of the ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery are described in a format that can be read and understood as a stand-alone document.
1,805 citations
TL;DR: It is suggested that every minute of delay in primary angioplasty for STEMI affects 1-year mortality, even after adjustment for baseline characteristics, and all efforts should be made to shorten the total ischemic time.
Abstract: Background— Although the relationship between mortality and time delay to treatment has been demonstrated in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, the impact of time delay on prognosis in patients undergoing primary angioplasty has yet to be clarified. The aim of this report was to address the relationship between time to treatment and mortality as a continuous function and to estimate the risk of mortality for each 30-minute delay. Methods and Results— The study population consisted of 1791 patients with STEMI treated by primary angioplasty. The relationship between ischemic time and 1-year mortality was assessed as a continuous function and plotted with a quadratic regression model. The Cox proportional hazards regression model was used to calculate relative risks (for each 30 minutes of delay), adjusted for baseline characteristics related to ischemic time. Variables related to time to treatment were age >70 years (P<0.0001), female gender (P=0....
1,410 citations
TL;DR: Enoxaparin has demonstrated advantages over unfractionated heparin in patients with non-ST-segment elevation acute coronary syndrome (ACS) treated with a conservative strategy.
Abstract: ContextEnoxaparin has demonstrated advantages over unfractionated heparin in
low- to moderate-risk patients with non–ST-segment elevation acute coronary
syndromes (ACS) treated with a conservative strategy.ObjectivesTo compare the outcomes of patients treated with enoxaparin vs unfractionated
heparin and to define the role of enoxaparin in patients with non–ST-segment
elevation ACS at high risk for ischemic cardiac complications managed with
an early invasive approach.Design, Setting, and ParticipantsThe Superior Yield of the New Strategy of Enoxaparin, Revascularization
and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial was a prospective, randomized,
open-label, multicenter, international trial conducted between August 2001
and December 2003. A total of 10 027 high-risk patients with non–ST-segment
elevation ACS to be treated with an intended early invasive strategy were
recruited.InterventionsSubcutaneous enoxaparin (n = 4993) or intravenous unfractionated heparin
(n = 4985) was to be administered immediately after enrollment and continued
until the patient required no further anticoagulation, as judged by the treating
physician.Main Outcome MeasuresThe primary efficacy outcome was the composite clinical end point of
all-cause death or nonfatal myocardial infarction during the first 30 days
after randomization. The primary safety outcome was major bleeding or stroke.ResultsThe primary end point occurred in 14.0% (696/4993) of patients assigned
to enoxaparin and 14.5% (722/4985) of patients assigned to unfractionated
heparin (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.86-1.06).
No differences in ischemic events during percutaneous coronary intervention
(PCI) were observed between enoxaparin and unfractionated heparin groups,
respectively, including similar rates of abrupt closure (31/2321 [1.3%] vs
40/2364 [1.7%]), threatened abrupt closure (25/2321 [1.1%] vs 24/2363 [1.0%]),
unsuccessful PCI (81/2281 [3.6%] vs 79/2328 [3.4%]), or emergency coronary
artery bypass graft surgery (6/2323 [0.3%] vs 8/2363 [0.3%]). More bleeding
was observed with enoxaparin, with a statistically significant increase in
TIMI (Thrombolysis in Myocardial Infarction) major bleeding (9.1% vs 7.6%, P = .008) but nonsignificant excess in GUSTO (Global Utilization
of Streptokinase and t-PA for Occluded Arteries) severe bleeding (2.7% vs
2.2%, P = .08) and transfusions (17.0% vs 16.0%, P = .16).ConclusionsEnoxaparin was not superior to unfractionated heparin but was noninferior
for the treatment of high-risk patients with non–ST-segment elevation
ACS. Enoxaparin is a safe and effective alternative to unfractionated heparin
and the advantages of convenience should be balanced with the modest excess
of major bleeding.
765 citations
TL;DR: Serum levels of the interleukin-1 receptor family member ST2 predict mortality and heart failure in patients with acute myocardial infarction, suggesting that ST2 may be a useful biomarker and that this novel inflammatory receptor may play a role in cardiac pathophysiology.
Abstract: Background— Mechanically overloaded cardiomyocytes secrete a soluble interleukin-1 receptor family member called ST2. Serum levels of ST2 are associated with prognosis in nonischemic heart failure, but the predictive value of ST2 in patients with acute myocardial infarction is unknown. Methods and Results— ST2 levels were measured in serum from 810 patients with acute myocardial infarction in the Thrombolysis In Myocardial Infarction (TIMI) 14 (362 patients) and Enoxaparin and TNK-tPA With or Without GPIIb/IIIa Inhibitor as Reperfusion Strategy in STEMI (ENTIRE)-TIMI 23 (448 patients) clinical trials. Baseline levels of ST2 were significantly higher in those patients who died (0.379 versus 0.233 ng/mL, P=0.0001) or developed new congestive heart failure (0.287 versus 0.233 ng/mL, P=0.009) by 30 days. In an analysis of outcomes at 30 days by ST2 quartiles, both death (P=0.001) and the combined death/heart failure end point (P=0.001) showed a significant graded association with levels of ST2; furthermore, i...
419 citations
TL;DR: In a systematic overview of approximately 22 000 patients across the spectrum of ACS, enoxaparin is more effective than unfractionated heparin in preventing the combined end point of death or MI.
Abstract: ContextAntithrombin therapy has become a guidelines-recommended standard of
care in the treatment of acute coronary syndromes (ACS), but recent trials
comparing use of enoxaparin and unfractionated heparin in ACS have yielded
less robust efficacy and safety results than have earlier trials of these
antithrombin therapies.ObjectiveTo systematically evaluate the end points of all-cause death and nonfatal
myocardial infarction (MI), transfusion, and major bleeding observed in the
6 randomized controlled trials comparing enoxaparin and unfractionated heparin
in treatment of ACS.Data SourcesThe primary data sets for ESSENCE, A to Z, and SYNERGY were available
at the Duke Clinical Research Institute. Baseline characteristics and event
frequencies for TIMI 11B, ACUTE II, and INTERACT were provided by the principal
investigator of each study.Study SelectionAll 6 randomized controlled trials comparing enoxaparin and unfractionated
heparin in non–ST-segment elevation ACS were selected for analysis.Data ExtractionEfficacy and safety end points were extracted from the overall trial
populations and the subpopulation receiving no antithrombin therapy prior
to randomization.Data SynthesisSystematic evaluation of the outcomes for 21 946 patients was performed
using a random-effects empirical Bayes model. No significant difference was
found in death at 30 days for enoxaparin vs unfractionated heparin (3.0% vs
3.0%; odds ratio [OR], 1.00; 95% confidence interval [CI], 0.85-1.17). A statistically
significant reduction in the combined end point of death or nonfatal MI at
30 days was observed for enoxaparin vs unfractionated heparin in the overall
trial populations (10.1% vs 11.0%; OR, 0.91; 95% CI, 0.83-0.99; number needed
to treat, 107). A statistically significant reduction in the combined end
point of death or MI at 30 days was also observed for enoxaparin in the populations
receiving no prerandomization antithrombin therapy (8.0% vs 9.4%; OR, 0.81;
95% CI, 0.70-0.94; number needed to treat, 72). No significant difference
was found in blood transfusion (OR, 1.01; 95% CI, 0.89-1.14) or major bleeding
(OR, 1.04; 95% CI, 0.83-1.30) at 7 days after randomization in the overall
safety population or in the population of patients receiving no prerandomization
antithrombin therapy.ConclusionIn a systematic overview of approximately 22 000 patients across
the spectrum of ACS, enoxaparin is more effective than unfractionated heparin
in preventing the combined end point of death or MI.
303 citations
TL;DR: Increased concentrations of BNP at initial presentation of patients with STEMI are associated with impaired reperfusion after fibrinolysis and higher short-term risk of mortality, and support the value of combining markers of hemodynamic stress with traditional approaches to risk assessment in acute myocardial infarction.
213 citations
TL;DR: Aspirin is effective in the short- and long-term prevention of adverse vascular events in high-risk patient groups, including those with ACS, stroke and peripheral arterial disease, and has been shown to reduce the frequency of ischemic complications after PCI.
Abstract: Although platelets lack nuclei and are the smallest circulating human cells, they play an integral and complex role in the process of thrombosis, both physiological and pathophysiological. Activation and aggregation of platelets play a central role in the propagation of intracoronary thrombi after (1) spontaneous atherosclerotic plaque disruption that results in myocardial ischemia or infarction in the acute coronary syndromes (ACS), or (2) the mechanical disruption that results from percutaneous coronary intervention (PCI). Platelets initially adhere to collagen and von Willebrand factor at the site of the disrupted plaque, resulting in an initial platelet monolayer. After activation, platelets release secondary agonists such as thromboxane A2 and adenosine diphosphate (ADP), which in combination with thrombin generated by the coagulation cascade result in stimulation and recruitment of additional platelets.1,2 With this pathophysiological background, it is not surprising that antiplatelet therapy is a cornerstone of the management of patients with ACS, especially those undergoing PCI.3–5
See p 3171
Aspirin inhibits cyclooxygenase (COX) by irreversible acetylation, which prevents the production of thromboxane A2. The antithrombotic effect of aspirin results from the decreased production of this prothrombotic, vasoconstrictive substance. Aspirin is effective in the short- and long-term prevention of adverse vascular events in high-risk patient groups, including those with ACS, stroke and peripheral arterial disease.6 Aspirin also has been shown to reduce the frequency of ischemic complications after PCI.7,8
Despite the impressive and consistent effects of aspirin in reducing adverse events in a variety of ischemic heart disease states, a significant rate of such events persists, and more potent antiplatelet agents, glycoprotein IIb/IIIa inhibitors, and thienopyridines have been developed. The thienopyridines irreversibly inhibit ADP binding to the P2Y12 receptor on the platelet surface. By blocking this receptor, these agents interfere with platelet activation, degranulation, and—by inhibiting the …
197 citations
TL;DR: In patients with UA/NSTEMI, there was a different pattern of presenting biomarkers, whereas women were more likely to have elevated C-reactive protein and brain natriuretic peptide, which suggests that a multimarker approach may aid the initial risk assessment of UA-N STEMI, especially in women.
Abstract: Background— Diagnosis of coronary artery disease in women is more difficult because of lower specificity of symptoms and diagnostic accuracy of noninvasive testing. We sought to examine the relationship between gender and cardiac biomarkers in patients with unstable angina (UA)/non–ST-segment elevation myocardial infarction (NSTEMI). Methods and Results— In the TACTICS-TIMI 18, OPUS-TIMI 16, and TIMI 11 studies, baseline samples were analyzed in the Thrombolysis In Myocardial Infarction (TIMI) biomarker core laboratory. We examined the relationship between gender and elevated biomarkers. Of 1865 patients from TACTICS-TIMI 18, 34% were women. Fewer women had elevated creatine kinase-MB or troponins, whereas more had elevated high-sensitivity C-reactive protein or brain natriuretic peptide. Presence of ST-segment deviation and TIMI risk scores were not significantly different. This pattern was confirmed in TIMI 11 and OPUS-TIMI 16. The prognostic value of the markers in TACTICS-TIMI 18 was similar in women ...
TL;DR: In the setting of NSTE-ACS, impaired GFR is associated with higher mortality as well as higher rates of thrombotic and major bleeding events, independent of TRS.
Abstract: Aims To determine the association of glomerular filtration rate (GFR) with clinical outcomes in the setting of non-ST-segment elevation acute coronary syndromes (NSTE-ACS).
Methods and results Data were pooled from five NSTE-ACS TIMI trials (TIMI 11A and B, TIMI 12, OPUS-TIMI 16 and TACTICS-TIMI 18) and were available in 13 307 patients. GFR was assessed as a continuous and a categorical variable (normal: ⩾90 mL/min/1.73 m2, n =4952; mildly decreased: 60-89 mL/min/1.73 m2, n =6262; and moderately to severely decreased GFR: <60 mL/min/1.73 m2, n =2093). There was an independent association between decreasing GFR and mortality at 30 days (OR 1.19, 95% CI 1.12–1.27, p <0.001) and at 6 months (OR 1.16, 95% CI 1.11–1.22, p <0.001). The combination of TIMI risk score (TRS) and decreasing GFR provided further mortality risk stratification with highest 30-day and 6-month mortality rates among patients with the lowest GFR who also had a TRS⩾5 (9.1% and 15.4%, respectively). Decreasing GFR was also independently associated with stroke and recurrent ischaemia at 30-days as well as with major bleeding ( p <0.001).
Conclusion In the setting of NSTE-ACS, impaired GFR is associated with higher mortality as well as higher rates of thrombotic and major bleeding events, independent of TRS.
TL;DR: Routine invasive therapy in UA/NSTEMI patients along with adjunctive use of glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival.
Abstract: Current evidence suggests that routine invasive therapy in the setting of unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) reduces the incidence of composite end points (i.e., death, myocardial infarction, or angina.). The 2002 American College of Cardiology/American Heart Association guidelines recommend invasive therapy in high-risk patients, although it is unknown if such an approach improves survival. We conducted a meta-analysis on 5 studies in 6,766 UA/NSTEMI patients who were randomized to either routine invasive versus conservative therapy in the era of glycoprotein IIb/IIIa inhibitors and intracoronary stents. Compared with conservative therapy, an invasive approach suggested a reduction in mortality at 6 to 12 months (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.63 to 1.03) and at 24 months (RR 0.77, 95% CI 0.60 to 0.99). The composite end point of death or myocardial infarction was reduced throughout all periods of follow-up: at 30 days (RR 0.61, 95% CI 0.45 to 0.84), at 6 months (RR 0.75, 95% CI 0.63 to 0.89), and at 12 months (RR 0.78, 95% CI 0.65 to 0.92). For the same composite end point at 6 to 12 months, men benefited from invasive therapy (RR 0.68, 95% CI 0.57 to 0.81), as did troponin-positive patients (RR 0.74, 95% CI 0.59 to 0.94). The results for women (RR 1.07, 95% CI 0.82 to 1.41) and troponin-negative patients (RR 0.82, 95% CI 0.59 to 1.14) were equivocal. Routine invasive therapy in UA/NSTEMI patients along with adjunctive use of glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival. Enhanced risk stratification is needed in women and troponin-negative patients so that invasive therapy may be more effectively recommended in these groups.
TL;DR: The mortality benefit associated with primary percutaneous coronary intervention in ST-segment elevation myocardial infarction may be lost if door-to-balloon time is delayed by >1 hour compared with tissue plasminogen activator therapy door- to-needle time.
Abstract: The mortality benefit associated with primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction may be lost if door-to-balloon time is delayed by >1 hour compared with tissue plasminogen activator therapy door-to-needle time. When a substantial delay in initiating primary PCI is likely, reperfusion therapy with second- or third-generation fibrinolytic agents should be strongly considered.
TL;DR: A simple risk index from baseline clinical variables routinely obtained at the first patient encounter predicted mortality in a large unselected heterogeneous group of patients with STEMI.
TL;DR: The APS combines grades of epicardial and tissue level perfusion before and after PCI or at the end of diagnostic cardiac catheterization to arrive at a single angiographic variable that is associated with infarct size and the rates of 30-day death or MI.
01 Jan 2004
TL;DR: Antman, Antman, MD, FACC, FAHA, Chair Sidney C. Smith, Jr. as mentioned in this paper and Vice Chair Joseph S. Ornato, MD FACC and FAHA.
Abstract: TASK FORCE MEMBERS Elliott M. Antman, MD, FACC, FAHA, Chair Sidney C. Smith, Jr., MD, FACC, FAHA, Vice Chair Joseph S. Alpert, MD, FACC, FAHA† Jeffrey L. Anderson, MD, FACC, FAHA David P. Faxon, MD, FACC, FAHA Valentin Fuster, MD, PhD FACC, FAHA Raymond J. Gibbons, MD, FACC, FAHA†‡ Gabriel Gregoratos, MD, FACC, FAHA† Jonathan L. Halperin, MD, FACC, FAHA Loren F. Hiratzka, MD, FACC, FAHA Sharon Ann Hunt, MD, FACC, FAHA Alice K. Jacobs, MD, FACC, FAHA Joseph P. Ornato, MD, FACC, FAHA
TL;DR: The TIMI IIIB and TACTICS-TIMI 18 trials as mentioned in this paper were two trials of an early invasive strategy in unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI) that were conducted nearly a decade apart but with virtually identical enrollment criteria and designs, except that upstream glycoprotein IIb/IIIa inhibition was mandated and coronary artery stenting was routinely used in TACS-TMI 18.
Abstract: Background— TIMI IIIB and TACTICS-TIMI 18 were 2 trials of an early invasive strategy in unstable angina (UA)/non–ST-elevation myocardial infarction (NSTEMI) that were conducted nearly a decade apart but with virtually identical enrollment criteria and designs, except that upstream glycoprotein IIb/IIIa inhibition was mandated and coronary artery stenting was routinely used in TACTICS-TIMI 18. We sought to examine the effect of these advances on clinical outcomes and the benefits of an early invasive strategy in UA/NSTEMI. Methods and Results— Patients were stratified on the basis of their TIMI risk score into low-, intermediate-, and high-risk categories. Within each risk category, the rates of clinical outcomes and the benefit of an early invasive strategy were compared. Compared with patients in TIMI IIIB and adjusting for baseline risk, patients in TACTICS-TIMI 18 had lower rates of death, MI, or rehospitalization for acute coronary syndromes (OR, 0.62; P<0.0001). Across both trials, the benefit of an...
TL;DR: A prolonged symptom to treatment time among STEMI patients is associated with impaired myocardial perfusion independent of epicardial flow both immediately after fibrinolytic administration and after rescue/adjunctive PCI, and these data provide a pathophysiologic link between prolonged symptoms due to vessel occlusion, impaired my cardiac perfusion, and poor clinical outcomes.
TL;DR: Care of patients with STEMI will be improved in the future if they are viewed as a single integrated effort at reperfusion, according to the authors.
Abstract: Prompt reperfusion of ischemic myocardium is the major focus of acute treatment of patients with ST-segment elevation myocardial infarction (STEMI). Two reperfusion strategies have been developed: pharmacological and catheter based. Although these two strategies have traditionally been considered distinct and at times competing options, it is likely that care of patients with STEMI will be improved in the future if they are viewed as a single integrated effort at reperfusion.
TL;DR: A new end point is proposed to evaluate the success of reperfusion therapy in patients who undergo early angiography, and attainment of the trifecta at 60 minutes remained a strong predictor of better clinical outcomes, particularly in those patients who underwent early PCI.
Abstract: The restoration of epicardial and myocardial flow remains the primary goal of reperfusion therapy in patients with ST-segment elevation myocardial infarction, but the optimal method to assess this goal has not been defined. Thrombolysis In Myocardial Infarction flow grade (TFG), myocardial perfusion grade (MPG), and ST-segment resolution (STRes) were combined to formulate a new measure of successful reperfusion in 649 patients who received pharmacologic reperfusion therapy in 3 recent phase II clinical trials of ST-segment elevation myocardial infarction. Coronary angiograms and electrocardiograms were analyzed at 60 minutes (before any intervention) after the initiation of reperfusion therapy. The complete restoration of perfusion, or the "trifecta," defined as the presence of TFG 3, MPG 3, and complete (> or =70%) STRes, occurred in 117 patients (18%). The achievement of this trifecta was associated with low rates of 30-day mortality (0% vs 3.9%, p = 0.02), congestive heart failure (CHF) (0.9% vs 7.1%, p = 0.01), and the combination of death or CHF (0.9% vs 10.7%, p = 0.001). When the results were stratified with respect to subsequent percutaneous coronary intervention (PCI) from 60 to 120 minutes, attainment of the trifecta at 60 minutes remained a strong predictor of better clinical outcomes, particularly in those patients who underwent early PCI. The achievement of TFG 3, MPG 3, and complete STRes at 60 minutes after fibrinolytic therapy and before PCI occurred in only 18% of patients but was associated with very low rates of death and CHF at 30 days. This new end point is proposed to evaluate the success of reperfusion therapy in patients who undergo early angiography.
TL;DR: Despite a higher risk profile, patients with more severe HF were treated less aggressively than patients without HF, and angiotensin-inhibitors and beta-blockers were not optimally utilised in patients with HF following MI.
Abstract: Aims To define the clinical characteristics, co-morbidities, treatment, and clinical outcomes of patients with varying degrees of heart failure (HF) complicating ST-elevation myocardial infarction (STEMI), and to identify patients at high risk for HF following fibrinolysis.
Methods and results 15,078 STEMI patients enrolled in a worldwide fibrinolytic trial (InTIME-II) were categorised into one of four hierarchical, mutually exclusive groups of HF: shock (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(n=719\) \end{document}, 5%); severe HF (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(n=1082\) \end{document}, 7%); mild HF (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(n=1619\) \end{document}, 11%); no HF (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(n=11,658\) \end{document}, 77%). In a multivariable model, anterior MI (OR 1.8, 95% CI [1.6; 1.9]), age ⩾65 (OR 1.8 [1.6; 2.0]), prior HF (OR 3.3 [2.6; 4.2]), and creatinine clearance \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \({<}\) \end{document}60 mL/min (OR 1.8 [1.6; 2.1]) were the four most powerful correlates of HF. Although 30-day mortality was sixfold higher for patients with HF (18.9% vs. 3.1%, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(p{<}0.0001\) \end{document}), these patients were less likely to undergo angiography (30% vs. 40%, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(p{<}0.0001\) \end{document}) and revascularisation (19% vs. 25%, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(p{<}0.0001\) \end{document}), than patients without HF. Likewise, angiotensin-inhibitors and β-blockers were not optimally utilised in patients with HF following MI.
Conclusions During the index admission following fibrinolysis 23% of patients had HF. Despite a higher risk profile, patients with more severe HF were treated less aggressively than patients without HF.
TL;DR: Data from this issue of the European Heart Journal demonstrate that among 1072 patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention (PCI), prolonged times between symptom onset and the first balloon inflation are associated with impaired ST-Segment resolution, impaired myocardian blush grades, larger infarct sizes and higher mortality.
Abstract: This editorial refers to “Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty”1 by G. De Luca et al. on page 1009
In this issue of the European Heart Journal , De Luca et al., demonstrate that among 1072 patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI), prolonged times between symptom onset and the first balloon inflation are associated with impaired ST-segment resolution, impaired myocardial blush grades, larger infarct sizes and higher mortality.1 These data add to a growing body of literature suggesting that renewed efforts are needed to reduce symptom-to-door and door-to-balloon times in order to improve myocardial perfusion, myocardial salvage and clinical outcomes among patients undergoing primary PCI for STEMI.1
While an association between prolonged door-to-balloon times and mortality has been described previously, the association of symptom-to-door and symptom-to-balloon times has not been as well established in its association with mortality.2 The demonstration of such an association may be hampered by survival bias: those patients with prolonged symptom-to-door times may not survive to be included in analyses such as the present one.2 It is noteworthy therefore that despite being enriched …
*Correspondence to: C. Michael Gibson, M.S., M.D., 350 Longwood Avenue, First Floor, Boston MA, USA. Tel.: +1-617525-6884; fax: +1-888-249-5261 E-mail address: mgibson{at}timi.org
TL;DR: A higher platelet count is independently associated with the presence of residual thrombus in the infarct-related artery after administration of fibrinolytic therapy, even after multivariate adjustment.
Abstract: A higher platelet count is independently associated with the presence of residual thrombus in the infarct-related artery after administration of fibrinolytic therapy, even after multivariate adjustment.
TL;DR: Higher post-fibrinolytic LVEDP was associated with age ≥65, female gender, Killip Class II–IV on presentation, and LAD culprit location, and elevated LVEDp was independently associated with a greater incidence of in-hospital and 30-day congestive heart failure.
Abstract: Unfavorable hemodynamics among patients with ST-elevation myocardial infarction (STEMI) have been associated with adverse clinical outcomes and may be linked to a failure to achieve complete reperfusion. We hypothesized that impaired epicardial and tissue-level perfusion after fibrinolytic therapy would be associated with adverse hemodynamics. The relationship between left ventricular end-diastolic pressure (LVEDP), baseline clinical characteristics, and angiographic findings were examined in 666 patients with STEMI treated with fibrinolytic therapy from the TIMI 14, INTEGRITI (TIMI 20), ENTIRE (TIMI 23), and FASTER (TIMI 24) trials. LVEDP was analyzed as a dichotomous variable with an elevated LVEDP defined as LVEDP >18 mmHg (median value). Higher post-fibrinolytic LVEDP was associated with age > or = 65, female gender, Killip Class II-IV on presentation, and LAD culprit location. Elevated LVEDP was associated with both a closed infarct-related artery (58.8% of TIMI Flow Grade (TFG) 0/1 with elevated LVEDP vs. 46.6% of TFG 2/3, p = 0.03) and impaired myocardial perfusion (55.7% of TIMI Myocardial Perfusion Grade (TMPG) 0/1 with elevated LVEDP vs. 43.8% of TMPG 2/3, p = 0.02). In a multivariate analysis, impaired myocardial perfusion (OR 1.7, p = 0.02), abnormal Killip Class (OR 4.8, p = 0.001), age > or = 65 (OR 1.6, p = 0.04), and female gender (OR 1.9, p = 0.01) were independently associated with elevated LVEDP. Elevated LVEDP was independently associated with a greater incidence of in-hospital (OR 11.8, p = 0.02) and 30-day congestive heart failure (OR 4.4, p = 0.02). In STEMI, angiographic indices of incomplete reperfusion are associated with an elevated LVEDP, and elevated LVEDP is associated with adverse clinical outcomes.
Georgia Regents University1, University of Arizona2, LDS Hospital3, Duke University4, Harvard University5, University of Virginia6, Merck & Co.7, Northwestern University8, American Heart Association9, University of California, San Francisco10, University of Minnesota11, American College of Cardiology12, University of California, Los Angeles13, University of Wisconsin-Madison14, University of Chicago15, Food and Drug Administration16, National Institutes of Health17, Mayo Clinic18, Icahn School of Medicine at Mount Sinai19, University of Pennsylvania20, Boston University21, American Board of Internal Medicine22, Association of American Medical Colleges23, Johns Hopkins University24, Washington University in St. Louis25, Boston Scientific Corporation26, Rush University Medical Center27, Cleveland Clinic28, Morehouse School of Medicine29, University of North Carolina at Chapel Hill30, University of Florida31, University of Michigan32, Stanford University33, University of Southern California34, University of Washington35, University of Texas at Austin36, Medical College of Wisconsin37, University of Pittsburgh38, University of Texas Health Science Center at Houston39, Cornell University40, Indiana University41
TL;DR: This document summarizes current capabilities, research and operational priorities, and plans for further studies that were established at the 2015 USGS workshop on quantitative hazard assessments of earthquake-triggered landsliding and liquefaction.
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TL;DR: The frequency distribution of the TIMI Risk Score, or similar tools for risk assessment, may be used to quantify and readily compare the risk profile of populations enrolled in clinical studies.
Abstract: Aims Interpreting the results and practice implications of clinical studies requires accurate characterisation of the baseline risk of the population. We evaluated the Thrombolysis in Myocardial Infarction (TIMI) risk score for STEMI as a tool to describe and compare the risk profile of populations enrolled in three clinical trials (InTIME-II, ASSENT-2 and MAGIC) and the National Registry of Myocardial Infarction.
Methods and Results The risk score was calculated for each patient \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((N=121,085)\) \end{document} and the frequency distribution plotted for each population. The Risk Score Profiles were compared using the Kolmogorov–Smirnov test. The Risk Score Profile demonstrated a striking concordance between the baseline risk of patients in InTIME-II and ASSENT-2 (median scores in each=\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(3[1,4]\) \end{document}, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P=0.11)\) \end{document}. In contrast, the distributions in MAGIC (designed to enroll high risk) and NRMI (registry) were shifted significantly toward higher risk (median scores=\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(4[3,5]\) \end{document} for MAGIC and \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(4[2,6]\) \end{document} in NRMI, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P{<}0.0001\) \end{document} for each vs. InTIME-II). A graded relationship between the risk score and mortality was evident in each study \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((P{<}0.0001)\) \end{document}.
Conclusions The frequency distribution of the TIMI Risk Score, or similar tools for risk assessment, may be used to quantify and readily compare the risk profile of populations enrolled in clinical studies.
TL;DR: In patients with UA/NSTEMI, a simple clinical risk score can aid in assessing the risk of developing CHF and B-type natriuretic peptide adds to the predictive capacity of this risk score.
TL;DR: Patients with prior stroke who present with STEMI are at very high risk for short-term morbidity and mortality and Aggressive treatment of these patients appears warranted.
TL;DR: In high-risk patients treated without PCI, tirofiban reduced the risk for death, myocardial infarction, and refractory ischemia at 30 days, and this benefit was similar in magnitude as that for patients who underwent PCI.
Abstract: Although the efficacy of glycoprotein IIb/IIIa inhibition in non–ST-elevation acute coronary syndromes is greatest in patients who undergo percutaneous coronary intervention (PCI), it was hypothesized that high-risk patients managed without PCI also benefit. The TIMI risk score was calculated for 1,570 patients randomized to tirofiban plus heparin versus heparin in the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms trial. In high-risk patients (score ≥4) treated without PCI, tirofiban reduced the risk for death, myocardial infarction, and refractory ischemia at 30 days (28.8% vs 21.9%; odds ratio [OR] 0.69, p = 0.04). This benefit was similar in magnitude as that for patients who underwent PCI (32.4% vs 22.2%; OR 0.60, p = 0.06). No benefit was evident in low-risk patients.