Single-lead ST-segment deviation after primary angioplasty
By Caroline Price
04 January 2008
Heart 2008; 94: 44-47
MedWire News: Residual ST-segment deviation in a single lead 3 hours after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is an “easy and accurate” predictor of 1-year mortality, cardiologists report.
Electrocardiography (ECG) is a simple way to measure reperfusion outcomes, with ST-segment deviation providing better prognostic accuracy than ST-segment resolution, explain A van’t Hof (Hospital De Weezenlanden, Zwolle, The Netherlands) and team.
To evaluate the prognostic role of postprocedural single-lead ST-segment deviation (STD) in primary angioplasty, relative to single-lead ST-segment resolution and elevation, and 12-lead ST-segment deviation, the researchers prospectively studied 1660 STEMI patients undergoing the procedure between 1997 and 2002.
Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow, residual stenosis <50%, and myocardial blush grade (MBG) 2-3. ECGs were recorded at 3 hours after the procedure.
As reported in the journal Heart, maximal residual STD correlated well with postprocedural MBG 3, distal embolization, enzymatic infarct size, and predischarge left ventricular ejection fraction.
At 1 year of follow-up, 63 (3.8%) patients had died. In multivariate analysis, after correction for baseline characteristics, maximal residual single-lead STD was the strongest predictor of mortality of all postprocedural ECG measures, at a hazard ratio of 1.87 (p<0.001).
Using receiver operating characteristic curves, the researchers identified ≥2 mm as the optimal threshold for maximal single-lead STD.
“The simple evaluation of maximal residual STD in a single lead 3 hours after the procedure is the best electrocardiographic measure for the evaluation of myocardial perfusion and prognostic stratification of patients with STEMI treated with primary angioplasty,” the authors write.
Link: http://heart.bmj.com/cgi/content/abstract/94/1/44
Showing posts with label STEMI. Show all posts
Showing posts with label STEMI. Show all posts
Friday, January 4, 2008
Thursday, December 20, 2007
Diagnosis of Heart Attack Can Be Wrong Study finds false positives occur 9.2% of the time in emergency rooms
Diagnosis of Heart Attack Can Be Wrong Study finds false positives occur 9.2% of the time in emergency rooms
TUESDAY, Dec. 18 (HealthDay News) -- When doctors in the emergency room believe that someone is having a heart attack, they are mistaken 9.2 percent of the time, a new study indicates.
Given that minutes matter with these patients and doctors have to act quickly in this setting, that percentage is tolerable, say researchers from the Minneapolis Heart Institute Foundation.
"Our conclusion is that an 8 to 10 percent false positive rate is acceptable," said study co-author Dr. Timothy Henry, who is director of the institute.
However, every effort should be taken to reduce the number of false positive diagnoses of heart attack, Henry added. The report, which is published in the Dec. 19 issue of the Journal of the American Medical Association, gives a benchmark for other institutions to meet, he said.
"The whole issue of false positive has never been presented," Henry said. "This is the first time it has been presented in a systematic way."
Henry and his colleagues studied the medical records of 1,345 people treated for suspected heart attacks in a regional system between 2003 and 2006, looking at emergency room decisions to activate the cardiac catheterization laboratory to treat for suspected heart attacks. Such decisions usually must be made in a matter of minutes, often without a record of a patient's previous cardiac history.
All the patients were suspected of having a STEMI heart attack, characterized by a specific electrocardiogram pattern. It turned out that 187 of them (14 percent) did not have obvious blockage of a coronary artery, with 127 (9.5 percent) having no significant coronary artery disease and 149 (11.2 percent) having negative results on cardiac biomarker tests. There was a significant difference in survival, with a 4.6 percent 30-day death rate for those with a blocked artery and 2.7 percent for those without blockage.
Hospitals should run a continuing check on such emergency room diagnoses and decisions, Henry said. "If they are too high, corrective action should be taken," he said.
Heart attack diagnosis has been the focus of "a number of quality improvement initiatives," said Dr. Frederick A. Masoudi, an associate professor of medicine at the Denver Health Medical Center, who wrote an accompanying editorial.
"It is well known that timing is of the essence in treating these patients," Masoudi said. "The outcome is better when the artery is opened in a timely way."
False positives are inevitable in some cases, he said. "It is really impossible to say from this one study whether there are too many or too few," Masoudi said. "Ultimately, it is important for us to evaluate the extent to which it occurs and why it occurs. We must build into the system a balance, so that only those patients who need reperfusion get it."
SOURCES: Timothy D. Henry, M.D., director, research, Minneapolis Heart Institute Foundation; Frederick A. Masoudi, M.D., associate professor, medicine, Denver Health Medical Center; Dec. 19, 2007, Journal of the American Medical Association
TUESDAY, Dec. 18 (HealthDay News) -- When doctors in the emergency room believe that someone is having a heart attack, they are mistaken 9.2 percent of the time, a new study indicates.
Given that minutes matter with these patients and doctors have to act quickly in this setting, that percentage is tolerable, say researchers from the Minneapolis Heart Institute Foundation.
"Our conclusion is that an 8 to 10 percent false positive rate is acceptable," said study co-author Dr. Timothy Henry, who is director of the institute.
However, every effort should be taken to reduce the number of false positive diagnoses of heart attack, Henry added. The report, which is published in the Dec. 19 issue of the Journal of the American Medical Association, gives a benchmark for other institutions to meet, he said.
"The whole issue of false positive has never been presented," Henry said. "This is the first time it has been presented in a systematic way."
Henry and his colleagues studied the medical records of 1,345 people treated for suspected heart attacks in a regional system between 2003 and 2006, looking at emergency room decisions to activate the cardiac catheterization laboratory to treat for suspected heart attacks. Such decisions usually must be made in a matter of minutes, often without a record of a patient's previous cardiac history.
All the patients were suspected of having a STEMI heart attack, characterized by a specific electrocardiogram pattern. It turned out that 187 of them (14 percent) did not have obvious blockage of a coronary artery, with 127 (9.5 percent) having no significant coronary artery disease and 149 (11.2 percent) having negative results on cardiac biomarker tests. There was a significant difference in survival, with a 4.6 percent 30-day death rate for those with a blocked artery and 2.7 percent for those without blockage.
Hospitals should run a continuing check on such emergency room diagnoses and decisions, Henry said. "If they are too high, corrective action should be taken," he said.
Heart attack diagnosis has been the focus of "a number of quality improvement initiatives," said Dr. Frederick A. Masoudi, an associate professor of medicine at the Denver Health Medical Center, who wrote an accompanying editorial.
"It is well known that timing is of the essence in treating these patients," Masoudi said. "The outcome is better when the artery is opened in a timely way."
False positives are inevitable in some cases, he said. "It is really impossible to say from this one study whether there are too many or too few," Masoudi said. "Ultimately, it is important for us to evaluate the extent to which it occurs and why it occurs. We must build into the system a balance, so that only those patients who need reperfusion get it."
SOURCES: Timothy D. Henry, M.D., director, research, Minneapolis Heart Institute Foundation; Frederick A. Masoudi, M.D., associate professor, medicine, Denver Health Medical Center; Dec. 19, 2007, Journal of the American Medical Association
Tuesday, December 11, 2007
Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction
Title: 2007 Focused Update of the 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Source: Developed in Collaboration With the Canadian Cardiovascular Society
Date Posted: 12/10/2007
Author(s): Antman EM, Hand M, Armstrong PW, et al., for the 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee.
Citation: J Am Coll Cardiol. 2008;51:[Epub ahead of print].
Perspective: The following are 10 points to remember about these updated guidelines:
1. Patients routinely taking nonsteroidal anti-inflammatory drugs (except for aspirin), both nonselective as well as cyclooxygenase-2 selective agents, before ST-elevation myocardial infarction (STEMI) should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use.
2. Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: a) signs of heart failure, b) evidence of a low output state, c) increased risk for cardiogenic shock, or d) other relative contraindications to beta blockade (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease).
3. STEMI patients presenting to a hospital with PCI capability should be treated with primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact as a systems goal.
4. STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated.
5. A strategy of coronary angiography with intent to perform PCI (or emergency coronary artery bypass graft surgery) is recommended for patients who have received fibrinolytic therapy and have any of the following: a) cardiogenic shock in patients <75 years who are suitable candidates for revascularization, b) severe congestive heart failure and/or pulmonary edema (Killip class III), or c) hemodynamically compromising ventricular arrhythmias.
6. Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days (regimens other than unfractionated heparin [UFH] are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment). Anticoagulant regimens with established efficacy include:a) UFH (initial intravenous [IV] bolus 60 U/kg [maximum 4000 U]) followed by an IV infusion of 12 U/kg/h (maximum 1000 U/h) initially, adjusted to maintain the activated partial thromboplastin time at 1.5-2.0 times control (~50-70 seconds).b) Enoxaparin (provided the serum creatinine is <2.5 mg/dl in men and 2.0 mg/dl in women): for patients <75 years of age, an initial 30 mg IV bolus is given, followed 15 minutes later by subcutaneous injections of 1.0 mg/kg every 12 hours; for patients at least 75 years of age, the initial IV bolus is eliminated and the subcutaneous dose is reduced to 0.75 mg/kg every 12 hours. Regardless of age, if the creatinine clearance (using the Cockroft-Gault formula) during the course of treatment is estimated to be <30 ml/min, the subcutaneous regimen is 1.0 mg/kg every 24 hours. Maintenance dosing with enoxaparin should be continued for the duration of the index hospitalization, up to 8 days.c) Fondaparinux (provided the serum creatinine is <3.0 mg/dl): initial dose 2.5 mg IV; subsequently subcutaneous injections of 2.5 mg once daily. Maintenance dosing with fondaparinux should be continued for the duration of the index hospitalization, up to 8 days.
7. Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days.
8. Every tobacco user and family members who smoke should be advised to quit at every visit.
9. For all post-PCI STEMI stented patients without aspirin resistance, allergy, or increased risk of bleeding, aspirin 162-325 mg daily should be given for at least 1 month after bare-metal stent (BMS) implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75-162 mg daily.
10. For all post-PCI patients who receive a drug-eluting stent, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). Debabrata Mukherjee, M.D., F.A.C.C.
Source: Developed in Collaboration With the Canadian Cardiovascular Society
Date Posted: 12/10/2007
Author(s): Antman EM, Hand M, Armstrong PW, et al., for the 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee.
Citation: J Am Coll Cardiol. 2008;51:[Epub ahead of print].
Perspective: The following are 10 points to remember about these updated guidelines:
1. Patients routinely taking nonsteroidal anti-inflammatory drugs (except for aspirin), both nonselective as well as cyclooxygenase-2 selective agents, before ST-elevation myocardial infarction (STEMI) should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use.
2. Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: a) signs of heart failure, b) evidence of a low output state, c) increased risk for cardiogenic shock, or d) other relative contraindications to beta blockade (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease).
3. STEMI patients presenting to a hospital with PCI capability should be treated with primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact as a systems goal.
4. STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated.
5. A strategy of coronary angiography with intent to perform PCI (or emergency coronary artery bypass graft surgery) is recommended for patients who have received fibrinolytic therapy and have any of the following: a) cardiogenic shock in patients <75 years who are suitable candidates for revascularization, b) severe congestive heart failure and/or pulmonary edema (Killip class III), or c) hemodynamically compromising ventricular arrhythmias.
6. Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days (regimens other than unfractionated heparin [UFH] are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment). Anticoagulant regimens with established efficacy include:a) UFH (initial intravenous [IV] bolus 60 U/kg [maximum 4000 U]) followed by an IV infusion of 12 U/kg/h (maximum 1000 U/h) initially, adjusted to maintain the activated partial thromboplastin time at 1.5-2.0 times control (~50-70 seconds).b) Enoxaparin (provided the serum creatinine is <2.5 mg/dl in men and 2.0 mg/dl in women): for patients <75 years of age, an initial 30 mg IV bolus is given, followed 15 minutes later by subcutaneous injections of 1.0 mg/kg every 12 hours; for patients at least 75 years of age, the initial IV bolus is eliminated and the subcutaneous dose is reduced to 0.75 mg/kg every 12 hours. Regardless of age, if the creatinine clearance (using the Cockroft-Gault formula) during the course of treatment is estimated to be <30 ml/min, the subcutaneous regimen is 1.0 mg/kg every 24 hours. Maintenance dosing with enoxaparin should be continued for the duration of the index hospitalization, up to 8 days.c) Fondaparinux (provided the serum creatinine is <3.0 mg/dl): initial dose 2.5 mg IV; subsequently subcutaneous injections of 2.5 mg once daily. Maintenance dosing with fondaparinux should be continued for the duration of the index hospitalization, up to 8 days.
7. Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days.
8. Every tobacco user and family members who smoke should be advised to quit at every visit.
9. For all post-PCI STEMI stented patients without aspirin resistance, allergy, or increased risk of bleeding, aspirin 162-325 mg daily should be given for at least 1 month after bare-metal stent (BMS) implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75-162 mg daily.
10. For all post-PCI patients who receive a drug-eluting stent, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). Debabrata Mukherjee, M.D., F.A.C.C.
Thursday, November 22, 2007
Treatment delays in reperfusion therapy increase mortality in STEMI patients
Treatment delays in reperfusion therapy increase mortality in STEMI patients
By Sara Carrillo de Albornoz
22 November 2007
Heart 2007; 93: 1552-1555
MedWire News: Patients presenting with ST-segment elevation myocardial infarction (STEMI) who experience long reperfusion therapy delays are at increased risk for death at 6 months, study findings indicate.
This higher 6-month mortality rate is more "critical" in patients receiving fibrinolytic therapy than in those undergoing primary percutaneous coronary intervention (PCI), Kim Eagle (University of Michigan Cardiovascular Center, Ann Arbor, USA) and colleagues add.
"Understanding the overall association between treatment delays and outcomes in reperfusion therapy for STEMI is critical for improving the selection and delivery of both fibrinolytic therapy and primary PCI in individual patients," the authors write in the journal Heart.
Eagle and team analyzed data from the multinational GRACE (Global registry of acute coronary events) trial to determine the association between treatment delays and 6-month mortality in 3959 STEMI patients treated with reperfusion therapy.
Of these, 1786 (45.1%) received fibrinolytic therapy and 2173 (54.9%) underwent primary PCI.
Patients receiving fibrinolytic therapy had a mean door-to-needle time of 35 minutes, while patients undergoing PCI had a mean door-to-balloon time of 78 minutes.
Multivariate analysis accounting for mortality risk factors such as age, cardiac arrest, and ST-changes showed that reperfusion treatment delays were associated with an increased 6-month mortality rate in both treatment groups (p<0.001).
Patients receiving fibrinolytic therapy had an 0.30% increase in 6-month mortality per 10-minute delay in door-to-needle time between 30 and 60 minutes, and those who underwent PCI had a 0.18% increased 6-month mortality per 10-minute delay in door-to-balloon time between 90 and 150 minutes.
Eagle et al conclude: "Although treatment delays are longer in primary PCI, their relationship with clinical outcomes is more gradual than that seen with fibrinolytic therapy.
"This important differential effect of treatment delays on outcome may influence the selection between these two reperfusion strategies in STEMI patients."
Free abstract
By Sara Carrillo de Albornoz
22 November 2007
Heart 2007; 93: 1552-1555
MedWire News: Patients presenting with ST-segment elevation myocardial infarction (STEMI) who experience long reperfusion therapy delays are at increased risk for death at 6 months, study findings indicate.
This higher 6-month mortality rate is more "critical" in patients receiving fibrinolytic therapy than in those undergoing primary percutaneous coronary intervention (PCI), Kim Eagle (University of Michigan Cardiovascular Center, Ann Arbor, USA) and colleagues add.
"Understanding the overall association between treatment delays and outcomes in reperfusion therapy for STEMI is critical for improving the selection and delivery of both fibrinolytic therapy and primary PCI in individual patients," the authors write in the journal Heart.
Eagle and team analyzed data from the multinational GRACE (Global registry of acute coronary events) trial to determine the association between treatment delays and 6-month mortality in 3959 STEMI patients treated with reperfusion therapy.
Of these, 1786 (45.1%) received fibrinolytic therapy and 2173 (54.9%) underwent primary PCI.
Patients receiving fibrinolytic therapy had a mean door-to-needle time of 35 minutes, while patients undergoing PCI had a mean door-to-balloon time of 78 minutes.
Multivariate analysis accounting for mortality risk factors such as age, cardiac arrest, and ST-changes showed that reperfusion treatment delays were associated with an increased 6-month mortality rate in both treatment groups (p<0.001).
Patients receiving fibrinolytic therapy had an 0.30% increase in 6-month mortality per 10-minute delay in door-to-needle time between 30 and 60 minutes, and those who underwent PCI had a 0.18% increased 6-month mortality per 10-minute delay in door-to-balloon time between 90 and 150 minutes.
Eagle et al conclude: "Although treatment delays are longer in primary PCI, their relationship with clinical outcomes is more gradual than that seen with fibrinolytic therapy.
"This important differential effect of treatment delays on outcome may influence the selection between these two reperfusion strategies in STEMI patients."
Free abstract
Sunday, October 14, 2007
Use caution with drug-eluting stents in patients with STEMI
Use caution with drug-eluting stents in patients with STEMI
VIENNA, Austria — Results from the GRACE registry suggest caution when considering drug-eluting stents in patients with ST-elevated myocardial infarction.
The Global Registry of Acute Coronary Events (GRACE) trial results, presented at the European Society of Cardiology Congress 2007, demonstrated that patients with STEMI were at an increased risk for mortality. More patients with STEMI had reinfarction than patients with bare metal stents.
“Personally, I never implant drug-eluting stents in patients with STEMI undergoing primary PCI nowadays,” said Philippe Gabriel Steg, MD, professor of cardiology at Hopital Bichat-Claude Bernard, Paris.
In other registry trial results presented at the congress, Stefan James, MD, said updated data from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) no longer indicated increased mortality in patients treated with drug-eluting stents vs. bare metal stents.
For more on GRACE, click here. For more on SCAAR, click here.
VIENNA, Austria — Results from the GRACE registry suggest caution when considering drug-eluting stents in patients with ST-elevated myocardial infarction.
The Global Registry of Acute Coronary Events (GRACE) trial results, presented at the European Society of Cardiology Congress 2007, demonstrated that patients with STEMI were at an increased risk for mortality. More patients with STEMI had reinfarction than patients with bare metal stents.
“Personally, I never implant drug-eluting stents in patients with STEMI undergoing primary PCI nowadays,” said Philippe Gabriel Steg, MD, professor of cardiology at Hopital Bichat-Claude Bernard, Paris.
In other registry trial results presented at the congress, Stefan James, MD, said updated data from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) no longer indicated increased mortality in patients treated with drug-eluting stents vs. bare metal stents.
For more on GRACE, click here. For more on SCAAR, click here.
Monday, September 3, 2007
ESC Congress - News - the DANAMI-2 trial - fibrinolytic therapy versus primary angioplasty in acute myocardial infarction
ESC Congress - News
The Danish multicenter randomised study of fibrinolytic therapy versus primary angioplasty in acute myocardial infarction (the DANAMI-2 trial). Outcome after three years follow-up.
Presenter report:
Nielsen, Torsten Toftegaard (Denmark)
Long-term randomized results on transfer for primary angioplasty (pPCI) versus on-site fibrinolysis for treatment of STEMI patients are sparse.The DANAMI-2 trial randomized 1572 STEMI patients to primary angioplasty (pPCI) or fibrinolysis (alteplase); 1129 of the patients were enrolled at 24 local hospitals without PCI facilities. Ninety-six percent of inter-hospital transfers for pPCI were completed within two hours. At 30 days, inter-hospital transfer for pPCI compared with fibrinolysis halved the primary composite endpoint of death, clinical reinfarction, or disabling stroke. The present study reports the long term (3 year) outcome. No patients were lost to follow-up.
The initial benefit of transfer for primary angioplasty based on the composite endpoint was sustained after three years (20.1 vs 26.7%, p=0.0007). Death occurred in 13.6 vs 16.4% (p=0.18), clinical reinfarction in 8.9% vs 12.3% (p=0.05), and disabling stroke in 3.2 vs 4.7% (p=0.23). Independent predictors of death were: clinical reinfarction, HR: 5.23 (3.63-7.54), anterior STEMI, HR.1.68 (1.26-2.23) and age, HR 1.08 (1.07-1.10).
We conclude that when inter-hospital transfer can be completed within two hours, primary angioplasty should be preferred over on-site fibrinolysis.
The Danish multicenter randomised study of fibrinolytic therapy versus primary angioplasty in acute myocardial infarction (the DANAMI-2 trial). Outcome after three years follow-up.
Presenter report:
Nielsen, Torsten Toftegaard (Denmark)
Long-term randomized results on transfer for primary angioplasty (pPCI) versus on-site fibrinolysis for treatment of STEMI patients are sparse.The DANAMI-2 trial randomized 1572 STEMI patients to primary angioplasty (pPCI) or fibrinolysis (alteplase); 1129 of the patients were enrolled at 24 local hospitals without PCI facilities. Ninety-six percent of inter-hospital transfers for pPCI were completed within two hours. At 30 days, inter-hospital transfer for pPCI compared with fibrinolysis halved the primary composite endpoint of death, clinical reinfarction, or disabling stroke. The present study reports the long term (3 year) outcome. No patients were lost to follow-up.
The initial benefit of transfer for primary angioplasty based on the composite endpoint was sustained after three years (20.1 vs 26.7%, p=0.0007). Death occurred in 13.6 vs 16.4% (p=0.18), clinical reinfarction in 8.9% vs 12.3% (p=0.05), and disabling stroke in 3.2 vs 4.7% (p=0.23). Independent predictors of death were: clinical reinfarction, HR: 5.23 (3.63-7.54), anterior STEMI, HR.1.68 (1.26-2.23) and age, HR 1.08 (1.07-1.10).
We conclude that when inter-hospital transfer can be completed within two hours, primary angioplasty should be preferred over on-site fibrinolysis.
ESC Congress - News - OASIS 5: Worse outcome with an invasive strategy among women with non ST-elevation acute coronary syndromes.
ESC Daily Congress News
OASIS 5: Worse outcome with an invasive strategy among women with non ST-elevation acute coronary syndromes.
Presenter report: Swahn, Eva (Sweden)
In patients with non ST-elevation acute coronary syndromes (NSTE ACS), subgroup analyses from several trials have shown a reduction in the composite of death and myocardial infarction with an early invasive strategy among men but a trend for harm amongst women. The aim of this study was to evaluate whether a routine early invasive strategy was superior to a selective invasive strategy in women.
Method
The OASIS 5 Women sub-study randomized 184 women with NSTE ACS to either an early invasive strategy with routine coronary angiography (and, if appropriate, coronary revascularization within 7 days) or to a selective invasive strategy with ischemia guided coronary angiography. The outcomes death, myocardial infarction, refractory ischemia, major bleeding and stroke were evaluated after 2 years.
Results
At one year follow-up 8 patients in the routine invasive group had died compared to 1 patient in the selective invasive group (8.8% vs 1.1%, p=0.013). There was no significant difference in either of the endpoints myocardial infarction (7.8% vs 9.9%, p= 0.634), refractory ischemia (4.4% vs 8.7%, p= 0.230) or stroke (2.3% vs 3.3%, p=0.872). Major bleedings were significantly more frequent in the routine invasive group (10.0% vs 1.1%, p= 0.002). The observed differences between the two groups, persisted at 2 years follow-up.
Conclusion
A routine invasive strategy was associated with an increased rate of major bleeding and mortality in women with NSTE ACS. As the majority of previous trials have predominantly enrolled men, a large randomized trial needs to be performed to determine the safety and efficacy of an early invasive approach in women.
Discussant : Rosengren, Annika (Sweden)
Background
One of the most conspicuous differences in ACS between men and women is that women are older at the onset than men, probably owing to the protective effect of estrogen which seems to delay atherosclerosis in the coronary vessels. Coronary angiography usually shows less extensive atherosclerosis in women. The differences in clinical presentation between men and women are more marked in younger, compared to older, patients. Women have less ST-elevation ACS but instead more NSTE. However, it should be noted that young women with ACS are a minority, and that the great majority of women who present with ACS are elderly. As a result of their older age many women with ACS have other diseases. The issue whether women with ACS should be treated the same as men has been much debated. There is still little consensus whether modern treatment in ACS is a help in women to the same extent as in men.
OASIS 5: Worse outcome with an invasive strategy among women with non ST-elevation acute coronary syndromes.
Presenter report: Swahn, Eva (Sweden)
In patients with non ST-elevation acute coronary syndromes (NSTE ACS), subgroup analyses from several trials have shown a reduction in the composite of death and myocardial infarction with an early invasive strategy among men but a trend for harm amongst women. The aim of this study was to evaluate whether a routine early invasive strategy was superior to a selective invasive strategy in women.
Method
The OASIS 5 Women sub-study randomized 184 women with NSTE ACS to either an early invasive strategy with routine coronary angiography (and, if appropriate, coronary revascularization within 7 days) or to a selective invasive strategy with ischemia guided coronary angiography. The outcomes death, myocardial infarction, refractory ischemia, major bleeding and stroke were evaluated after 2 years.
Results
At one year follow-up 8 patients in the routine invasive group had died compared to 1 patient in the selective invasive group (8.8% vs 1.1%, p=0.013). There was no significant difference in either of the endpoints myocardial infarction (7.8% vs 9.9%, p= 0.634), refractory ischemia (4.4% vs 8.7%, p= 0.230) or stroke (2.3% vs 3.3%, p=0.872). Major bleedings were significantly more frequent in the routine invasive group (10.0% vs 1.1%, p= 0.002). The observed differences between the two groups, persisted at 2 years follow-up.
Conclusion
A routine invasive strategy was associated with an increased rate of major bleeding and mortality in women with NSTE ACS. As the majority of previous trials have predominantly enrolled men, a large randomized trial needs to be performed to determine the safety and efficacy of an early invasive approach in women.
Discussant : Rosengren, Annika (Sweden)
Background
One of the most conspicuous differences in ACS between men and women is that women are older at the onset than men, probably owing to the protective effect of estrogen which seems to delay atherosclerosis in the coronary vessels. Coronary angiography usually shows less extensive atherosclerosis in women. The differences in clinical presentation between men and women are more marked in younger, compared to older, patients. Women have less ST-elevation ACS but instead more NSTE. However, it should be noted that young women with ACS are a minority, and that the great majority of women who present with ACS are elderly. As a result of their older age many women with ACS have other diseases. The issue whether women with ACS should be treated the same as men has been much debated. There is still little consensus whether modern treatment in ACS is a help in women to the same extent as in men.
Tuesday, August 14, 2007
Diabetes and Mortality Following Acute Coronary Syndromes
Diabetes and Mortality Following Acute Coronary Syndromes
JAMA. 2007;298:765-775.
Sean M. Donahoe, MD; Garrick C. Stewart, MD; Carolyn H. McCabe, BS; Satishkumar Mohanavelu, MS; Sabina A. Murphy, MPH; Christopher P. Cannon, MD; Elliott M. Antman, MD
Context The worldwide epidemic of diabetes mellitus is increasing the burden of cardiovascular disease, the leading cause of death among persons with diabetes. The independent effect of diabetes on mortality following acute coronary syndromes (ACS) is uncertain.
Objective To evaluate the influence of diabetes on mortality following ACS using a large database spanning the full spectrum of ACS.
Design, Setting, and Patients A subgroup analysis of patients with diabetes enrolled in randomized clinical trials that evaluated ACS therapies. Patients with ACS in 11 independent Thrombolysis in Myocardial Infarction (TIMI) Study Group clinical trials from 1997 to 2006 were pooled, including 62 036 patients (46 577 with ST-segment elevation myocardial infarction [STEMI] and 15 459 with unstable angina/non-STEMI [UA/NSTEMI]), of whom 10 613 (17.1%) had diabetes. A multivariable model was constructed to adjust for baseline characteristics, aspects of ACS presentation, and treatments for the ACS event.
Main Outcome Measures Mortality at 30 days and 1 year following ACS among patients with diabetes vs patients without diabetes.
Results Mortality at 30 days was significantly higher among patients with diabetes than without diabetes presenting with UA/NSTEMI (2.1% vs 1.1%, P < .001) and STEMI (8.5% vs 5.4%, P < .001). After adjusting for baseline characteristics and features and management of the ACS event, diabetes was independently associated with higher 30-day mortality after UA/NSTEMI (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.24-2.56) or STEMI (OR, 1.40; 95% CI, 1.24-1.57). Diabetes at presentation with ACS was associated with significantly higher mortality 1 year after UA/NSTEMI (hazard ratio [HR], 1.65; 95% CI, 1.30-2.10) or STEMI (HR, 1.22; 95% CI, 1.08-1.38). By 1 year following ACS, patients with diabetes presenting with UA/NSTEMI had a risk of death that approached patients without diabetes presenting with STEMI (7.2% vs 8.1%). Conclusion Despite modern therapies for ACS, diabetes confers a significant adverse prognosis, which highlights the importance of aggressive strategies to manage this high-risk population with unstable ischemic heart disease.
JAMA. 2007;298:765-775.
Sean M. Donahoe, MD; Garrick C. Stewart, MD; Carolyn H. McCabe, BS; Satishkumar Mohanavelu, MS; Sabina A. Murphy, MPH; Christopher P. Cannon, MD; Elliott M. Antman, MD
Context The worldwide epidemic of diabetes mellitus is increasing the burden of cardiovascular disease, the leading cause of death among persons with diabetes. The independent effect of diabetes on mortality following acute coronary syndromes (ACS) is uncertain.
Objective To evaluate the influence of diabetes on mortality following ACS using a large database spanning the full spectrum of ACS.
Design, Setting, and Patients A subgroup analysis of patients with diabetes enrolled in randomized clinical trials that evaluated ACS therapies. Patients with ACS in 11 independent Thrombolysis in Myocardial Infarction (TIMI) Study Group clinical trials from 1997 to 2006 were pooled, including 62 036 patients (46 577 with ST-segment elevation myocardial infarction [STEMI] and 15 459 with unstable angina/non-STEMI [UA/NSTEMI]), of whom 10 613 (17.1%) had diabetes. A multivariable model was constructed to adjust for baseline characteristics, aspects of ACS presentation, and treatments for the ACS event.
Main Outcome Measures Mortality at 30 days and 1 year following ACS among patients with diabetes vs patients without diabetes.
Results Mortality at 30 days was significantly higher among patients with diabetes than without diabetes presenting with UA/NSTEMI (2.1% vs 1.1%, P < .001) and STEMI (8.5% vs 5.4%, P < .001). After adjusting for baseline characteristics and features and management of the ACS event, diabetes was independently associated with higher 30-day mortality after UA/NSTEMI (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.24-2.56) or STEMI (OR, 1.40; 95% CI, 1.24-1.57). Diabetes at presentation with ACS was associated with significantly higher mortality 1 year after UA/NSTEMI (hazard ratio [HR], 1.65; 95% CI, 1.30-2.10) or STEMI (HR, 1.22; 95% CI, 1.08-1.38). By 1 year following ACS, patients with diabetes presenting with UA/NSTEMI had a risk of death that approached patients without diabetes presenting with STEMI (7.2% vs 8.1%). Conclusion Despite modern therapies for ACS, diabetes confers a significant adverse prognosis, which highlights the importance of aggressive strategies to manage this high-risk population with unstable ischemic heart disease.
Wednesday, July 11, 2007
PCI benefits over fibrinolysis found in diabetic patients
MedWire News - Cardiology - PCI benefits over fibrinolysis found in diabetic patients
PCI benefits over fibrinolysis found in diabetic patients
11 July 2007
Arch Intern Med 2007; 167: 1353-1359
MedWire News: The beneficial effects of primary percutaneous coronary intervention (PCI) over reperfusion therapy in diabetic patients with ST-segment elevation myocardial infarction (STEMI) are consistent with those for non-diabetic patients, meta-analysis findings indicate.
Writing in the Archives of Internal Medicine, Jan Paul Ottervanger (Isala Klinieken, Zwolle, The Netherlands) and colleagues note that an increasing amount of evidence indicates that primary PCI improves outcomes of STEMI compared with fibrinolysis in the general population. But effects of both reperfusion and fibrinolysis may differ in diabetic patients, they say, and previous trials comparing the strategies in diabetic patients have produced conflicting data.
"In our analysis including a large number of patients, it was more clearly demonstrated that primary PCI is associated with improved survival after 30 days in both patients with and without diabetes," the team reports.
The researchers analyzed data from 19 trials that compared primary PCI with fibrinolysis for STEMI in a total of 6315 patients, 877 (14%) of whom had diabetes.
At 30 days, 401 (6.3%) patients had died. Mortality was significantly higher in patients with than without diabetes (9.4% vs 5.9%, p<0.001).
Primary PCI was associated with lower mortality than fibrinolysis in both non-diabetic patients (4.8% vs 6.9%, unadjusted odds ratio [OR]=0.69; p=0.001) and diabetic patients (6.6% vs 12.4%, OR=0.49; p=0.001).
Recurrent MI and stroke were also less common with PCI in patients with and without diabetes, with corresponding ORs of 0.33 and 0.60, and 0.58 and 0.40.
After adjusting for potential confounders, including age, gender, time to randomization, treatment delay, systolic blood pressure, anterior MI, previous MI, heart rate, and randomized treatment, primary PCI was independently associated with reduced 30-day survival (OR=0.64). This association held true in patients with diabetes (OR=0.50) and without diabetes (OR=0.68).
The authors note that these point estimates indicate a greater benefit of PCI in diabetic patients, in whom the absolute risk is higher than in non-diabetic patients.
"This observation may be the result of delay in initiation of therapy and longer ischemic time in diabetic patients, which may be related in part to atypical symptoms," they write. "In particular, thrombolytic therapy seems to be negatively influenced by longer time to initiation of therapy."
They add that impairment of microvascular flow after fibrinolysis in diabetic patients could also contribute to a more favorable effect with PCI.
"Wider application of timely primary PCI could be an important strategy to improve outcomes in the high-risk population of diabetic patients," Timmer and co-authors conclude.
Free abstract
PCI benefits over fibrinolysis found in diabetic patients
11 July 2007
Arch Intern Med 2007; 167: 1353-1359
MedWire News: The beneficial effects of primary percutaneous coronary intervention (PCI) over reperfusion therapy in diabetic patients with ST-segment elevation myocardial infarction (STEMI) are consistent with those for non-diabetic patients, meta-analysis findings indicate.
Writing in the Archives of Internal Medicine, Jan Paul Ottervanger (Isala Klinieken, Zwolle, The Netherlands) and colleagues note that an increasing amount of evidence indicates that primary PCI improves outcomes of STEMI compared with fibrinolysis in the general population. But effects of both reperfusion and fibrinolysis may differ in diabetic patients, they say, and previous trials comparing the strategies in diabetic patients have produced conflicting data.
"In our analysis including a large number of patients, it was more clearly demonstrated that primary PCI is associated with improved survival after 30 days in both patients with and without diabetes," the team reports.
The researchers analyzed data from 19 trials that compared primary PCI with fibrinolysis for STEMI in a total of 6315 patients, 877 (14%) of whom had diabetes.
At 30 days, 401 (6.3%) patients had died. Mortality was significantly higher in patients with than without diabetes (9.4% vs 5.9%, p<0.001).
Primary PCI was associated with lower mortality than fibrinolysis in both non-diabetic patients (4.8% vs 6.9%, unadjusted odds ratio [OR]=0.69; p=0.001) and diabetic patients (6.6% vs 12.4%, OR=0.49; p=0.001).
Recurrent MI and stroke were also less common with PCI in patients with and without diabetes, with corresponding ORs of 0.33 and 0.60, and 0.58 and 0.40.
After adjusting for potential confounders, including age, gender, time to randomization, treatment delay, systolic blood pressure, anterior MI, previous MI, heart rate, and randomized treatment, primary PCI was independently associated with reduced 30-day survival (OR=0.64). This association held true in patients with diabetes (OR=0.50) and without diabetes (OR=0.68).
The authors note that these point estimates indicate a greater benefit of PCI in diabetic patients, in whom the absolute risk is higher than in non-diabetic patients.
"This observation may be the result of delay in initiation of therapy and longer ischemic time in diabetic patients, which may be related in part to atypical symptoms," they write. "In particular, thrombolytic therapy seems to be negatively influenced by longer time to initiation of therapy."
They add that impairment of microvascular flow after fibrinolysis in diabetic patients could also contribute to a more favorable effect with PCI.
"Wider application of timely primary PCI could be an important strategy to improve outcomes in the high-risk population of diabetic patients," Timmer and co-authors conclude.
Free abstract
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