Showing papers by "Eugene Braunwald published in 1994"

Diagnosing and managing unstable angina. Agency for Health Care Policy and Research.

Abstract: This Quick Reference Guide for Clinicians contains recommendations on the care of patients with unstable angina based on a combination of evidence obtained through extensive literature reviews and consensus among members of an expert panel Principal conclusions include the following (1) Many patients suspected of having unstable angina can be discharged home after adequate initial evaluation (2) Further outpatient evaluation may be scheduled for up to 72 hours after initial presentation for patients with clinical symptoms of unstable angina judged at initial evaluation to be at low risk for complications (3) Patients with acute ischemic heart disease judged to be at intermediate or high risk of complications should be hospitalized for careful monitoring of their clinical course (4) Intravenous thrombolytic therapy should not be administered to patients without evidence of ST segment elevation and acute myocardial infarction (5) Assessment of prognosis by noninvasive testing often aids selection of appropriate therapy (6) Coronary angiography is appropriate for patients judged to be at high risk for cardiac complications or death based on their clinical course or results of noninvasive testing (7) Coronary artery bypass surgery should be recommended for almost all patients with left main disease and many patients with three-vessel disease, especially those with left ventricular dysfunction (8) The discharge care plan should include continued monitoring of symptoms; appropriate drug therapy, including aspirin; risk-factor modification; and counseling

Comparison of Clinical Outcomes for Women and Men after Acute Myocardial Infarction

Abstract: Objectives: To assess differences in morbidity and mortality between men and women with acute myocardial infarction treated with thrombolytic therapy and the relation of differences to baseline pat...

Clinical and arteriographic characterization of patients with unstable angina without critical coronary arterial narrowing (from the TIMI-IIIA trial)

Abstract: Previous studies have reported that some patients presenting with unstable angina are found at coronary angiography to have no critical coronary stenosis. This study evaluated the clinical presentation and arteriographic findings in patients enrolled in the Thrombolysis in Myocardial Ischemia (TIMI-IIIA) trial, which assessed the effect of tissue-type plasminogen activator added to conventional therapy on the coronary arteriographic findings in patients presenting with ischemic pain at rest. Three hundred ninety-one patients were enrolled in the TIMI-IIIA trial and underwent coronary arteriography within 12 hours of enrollment. Fifty-three patients (14%) had no luminal diameter stenosis of a major coronary artery of > or = 60% on the baseline arteriogram. Compared with patients with unstable angina with an identifiable culprit lesion, patients without critical coronary obstruction were more likely to be women and non-white and less likely to have ST-segment deviation on the presenting electrocardiogram. Arteriography in such patients revealed no visually detectable coronary stenosis in half of the group; the remaining patients had noncritical coronary narrowing (i.e., < 60% luminal diameter stenosis) without morphologic features (ulceration or thrombus) suggestive of unstable or active coronary plaque. Nearly one third of the patients without critical coronary stenosis had impaired angiographic filling, suggesting a possible pathophysiologic role for coronary microvascular dysfunction. These patients with unstable angina and no critical coronary obstruction had an excellent short-term prognosis; 2% died or had myocardial infarction compared with 18% of patients with critical obstruction.

Time as an Adjunctive Agent to Thrombolytic Therapy.

Abstract: Thrombolytic therapy has dramatically reduced mortality following acute myocardial infarction (MI) with the major effect coming fromearly achievement of infarct-related artery patency. A major factor in achieving rapid reperfusion is early treatment with thrombolytic therapy. Recent trials have shown that mortality can be reduced if time to treatment is shortened: In the Thrombolysis in Myocardial Infarction (TIMI) 2 trial, for each hour earlier that thrombolytic therapy was started, approximately 10 lives were saved per 1000 patients treated. Thus, one must considertime as an adjunctive agent to thrombolytic therapy. There are four components of the time delay between the onset of MI and achievement of reperfusion: (1) patient delays in seeking medical attention; (2) transport delays; (3) the so-called door to needle time, the interval between the patient's arrival at the medical facility and the initiation of thrombolytic therapy; and (4) thrombolytic reperfusion time, the time between the administration of thrombolytic therapy and the achievement of reperfusion. Efforts to reduce each of these components will lead to additive benefits in improving time to reperfusion and survival of patients with acute MI.

Uniformity of captopril benefit in the SAVE study : subgroup analysis

Abstract: The Survival and Ventricular Enlargement (SAVE) Study demonstrated that long-term administration of the angiotensin-converting enzyme inhibitor captopril to recent survivors of myocardial infarction with left ventricular dysfunction resulted in a reduction in cardiovascular mortality and morbidity. Analysis of multiple subgroups demonstrated that baseline demographics (older age) and clinical characteristics (such as prior MI, history of diabetes or hypertension), that have previously been associated with a higher risk of cardiovascular events, were associated with greater end point event rates in SAVE regardless of therapy assignment at the time of randomization. The effectiveness of captopril therapy in reducing cardiovascular mortality and morbidity was examined in multiple subgroups. Although not all subgroups provided adequate statistical power, the benefits of captopril therapy were relatively uniform in the SAVE study. This indicates that the benefits were not confined to one particular subgroup and conversely that targeting of captopril therapy should be to the broadest group, as defined by SAVE entry criteria, to result in a reduction in cardiovascular mortality and morbidity.

The Thrombolysis in Myocardial Infarction (TIMI) Trial

Abstract: Thrombolytic therapy for acute myocardial infarction has been one of the major advances in cardiology occurring during the last decade and a half. The Thrombolysis in Myocardial Infarction (TIMI) trials are a series of studies begun in 1984, initially under the sponsorship of the National Heart Lung and Blood Institute. A list of TIMI trials is shown in Table 1. The TIMI 1 trial investigated the relative efficacy of intravenous streptokinase and tissue-type plasminogen activator (t-PA). The TIMI 2 trial examined three strategies for acute MI, focusing on the role of adjunctive angioplasty following thrombolytic therapy, either immediately, routinely or as clinically warranted by recurrent ischemia. The TIMI 3 trial explored the role of thrombolytic therapy across the spectrum of acute ischemic syndromes, focusing on unstable angina and non-Q wave MI, and on the role of an early invasive strategy. The TIMI 4 trial tested two new regimens of thrombolytic therapy, front-loaded t-PA and combination thrombolytic therapy, against standard therapy with a non-fibrin specific agent. The TIMI 5 and 6 trials were pilot trials comparing the new thrombin inhibitor hirudin to heparin given in conjunction with aspirin and t-PA or streptokinase respectively. The TIMI 7 trial was a dose ranging trial of the specific thrombin inhibitor hirulog, for patients with unstable angina. The TIMI 8 trial will be a large scale clinical trial comparing hirulog to heparin in patients with the acute ischemic syndromes of unstable angina and non-Q wave MI, and TIMI 9 will be a large scale clinical trial comparing hirudin to heparin in conjunction with thrombolytic therapy for acute myocardial infarction. This chapter will highlight the major findings of the trials with data available as of this writing.

Diagnosing and Managing Unstable Angina, Quick Reference Guide for Clinicians

Abstract: Introducing a new hobby for other people may inspire them to join with you. Reading, as one of mutual hobby, is considered as the very easy hobby to do. But, many people are not interested in this hobby. Why? Boring is the reason of why. However, this feel actually can deal with the book and time of you reading. Yeah, one that we will refer to break the boredom in reading is choosing diagnosing and managing unstable angina quick reference guide for clinicians as the reading material.

Diagnosing and managing unstable angina

Abstract: This Quick Reference Guide for Clinicians contains recommendations on the care of patients with unstable angina based on a combination of evidence obtained through extensive literature reviews and consensus among members of an expert panel. Principal conclusions include the following. (1) Many patients suspected of having unstable angina can be discharged home after adequate initial evaluation. (2) Further outpatient evaluation may be scheduled for up to 72 hours after initial presentation for patients with clinical symptoms of unstable angina judged at initial evaluation to be at low risk for complications. (3) Patients with acute ischemic heart disease judged to be at intermediate or high risk of complications should be hospitalized for careful monitoring of their clinical course. (4) Intravenous thrombolytic therapy should not be

Comparison of patients with <60%to≥60% diameter narrowing of the myocardial infarct-related artery after thrombolysis

Abstract: The purpose of this study was to analyze angiographic findings, clinical course, and follow-up data on 1,752 patients who underwent protocol cardiac catheterization 18 to 48 hours after enrollment in the Thrombolysis in Myocardial Infarction (TIMI) II pilot and randomized trial: 244 patients (14.0%) had or = 60% in diameter with TIMI grade 2 or 3 flow, and 259 patients (15%) had TIMI grade 0 or 1 flow (total occlusion). Patients with 55% (p or = 60% and TIMI grade 2 or 3 flow (p = 0.05) and 7.0% for patients with total occlusion (p = 0.004). Patients with stenosis < 60% in the infarct-related artery 18 to 48 hours after thrombolytic therapy have a good prognosis. Infarct artery status predicts predischarge ejection fraction and 1-year mortality.