Background In the setting of non ST segment elevation (NSTE) acute coronar y syndromes(ACS), the pathophysiological mechanisms underlying post percutaneou s coronary intervention (PCI) cardiac troponin I (cTnI) elevat...Background In the setting of non ST segment elevation (NSTE) acute coronar y syndromes(ACS), the pathophysiological mechanisms underlying post percutaneou s coronary intervention (PCI) cardiac troponin I (cTnI) elevation remain unclear . Methods and Results We evaluated the relationship between troponin elevation and tissue level perfusion using the TIMI flow grade, corrected TIMI frame coun t, TIMI myocardial perfusion grade(TMPG), andmyocardial contrast enhancement by intracoronary myocardial contrast echocardiography (MCE) before and immediately after PCI performed within 24 to 48 hours of hospital admission in 42 high ris k(angina at rest, unequivocal ST segment depression, and cTnI elevation) patien ts with NSTE ACS. All patients were treated with glycoprotein IIb/IIIa inhibito rs (27 with tirofiban and 15 with abciximab) and had successful PCI. Fourteen p atients had a postprocedural cTnI elevation, whereas 28 did not. TMPG 0/1 after PCI was observed more frequently in patients with postprocedural cTnI elevation (43%versus 7%; P< 0.02). cTnI levels were higher among patients with TMPG 0/1 versus patients with TMPG 2/3 (5.3±2.7 versus 1.5±1.3 ng/mL; P< 0.0001). Patie nts with postprocedural cTnI elevation also presented a significantly lower numb er of perfused segments at MCE (59%versus 81%; P=0.02) as well as a lower MCE score index (0.65±0.38 versus 0.89±0.21; P < 0.02). Conclusions Postp rocedu ral cTnI elevation in high risk patients with NSTE ACS is associated with an a bnormal tissue level perfusion.展开更多
Background Most patients with acute myocardial infarction (AMI) are admitted t o hospitals without percutaneous transluminal coronary angioplasty (PTCA) facili ties or are initially managed in a prehospital mobile uni...Background Most patients with acute myocardial infarction (AMI) are admitted t o hospitals without percutaneous transluminal coronary angioplasty (PTCA) facili ties or are initially managed in a prehospital mobile unit. Thrombolysis remains the most readily available reperfusion treatment in those settings, but the opt imal subsequent strategy in those patients is unclear. If a mechanical recanaliz ation is likely to be performed in an emergency, it is probably desirable that t he patient receives abciximab, the glycoprotein IIb/IIIa antagonist with the str ongest evidence of benefit for angioplasty in AMI. Objective The aim of this tri al is to compare the effects on clinical outcome and cost effectiveness of 2 st rategies after immediate treatment with abciximab and half dose reteplase for S T elevation AMI: to manage the patients conservatively (referring them for resc ue PTCA only if needed) or to immediately send all patients for emergency corona ry angioplasty. Methods The Combined Abciximab RE teplase Stent Study in Acute Myocardial Infarction(CARESS in AMI) is an open, prospective, randomized,multicenter clinical trial conducted in patients with high risk ST segment elevation AMI treated within 12 hours from symptom onset in hospitals without PTCA facilities or in a prehospital mobile intensive care u nit. Apart from contraindications to thrombolysis, themain exclusion criteria ar e age ≥75 years and a past history of CABG surgery or a percutaneous coronary i ntervention procedure involving the infarct related artery. Enrollment will be performed in hospitals without PTCA facilities or directly in the ambulance if a dedicated system is in place for prehospital diagnosis and treatment of AMI. Pa tients will receive half dose reteplase and full dose abciximab and will subse quently be randomized to conventional medical therapy (with referral for emergen cy rescue PTCA allowed in selected cases) or emergency angioplasty. The primary end point is the 30-day combined incidence of mortality, reinfarction, and refr actory ischemia. In order to obtain a 95%power (2-sided) to detect a 42%reduc tion in the primary end point, 900 patients are required in each arm of the stud y. Secondary end points include the 1-year composite end point of mortality, re infarction, refractory ischemia, and hospital readmission because of heart failu re; resource use at 30 days and 1 year; and the incidence of inhospital stroke a nd bleeding complications in the 2 groups. Results Seventy four patients have b een randomized (as of March 10, 2004); results are expected in June 2005. Conclu sion This study will establish whether angioplasty must be started as soon as po ssible in all patients who receive combined pharmacologic reperfusion with the g lycoprotein IIb/IIIa inhibitor abciximab and half dose thrombolysis or whether it can be postponed or skipped in patients with signs of successful reperfusion, with obvious organizational advantages.展开更多
文摘Background In the setting of non ST segment elevation (NSTE) acute coronar y syndromes(ACS), the pathophysiological mechanisms underlying post percutaneou s coronary intervention (PCI) cardiac troponin I (cTnI) elevation remain unclear . Methods and Results We evaluated the relationship between troponin elevation and tissue level perfusion using the TIMI flow grade, corrected TIMI frame coun t, TIMI myocardial perfusion grade(TMPG), andmyocardial contrast enhancement by intracoronary myocardial contrast echocardiography (MCE) before and immediately after PCI performed within 24 to 48 hours of hospital admission in 42 high ris k(angina at rest, unequivocal ST segment depression, and cTnI elevation) patien ts with NSTE ACS. All patients were treated with glycoprotein IIb/IIIa inhibito rs (27 with tirofiban and 15 with abciximab) and had successful PCI. Fourteen p atients had a postprocedural cTnI elevation, whereas 28 did not. TMPG 0/1 after PCI was observed more frequently in patients with postprocedural cTnI elevation (43%versus 7%; P< 0.02). cTnI levels were higher among patients with TMPG 0/1 versus patients with TMPG 2/3 (5.3±2.7 versus 1.5±1.3 ng/mL; P< 0.0001). Patie nts with postprocedural cTnI elevation also presented a significantly lower numb er of perfused segments at MCE (59%versus 81%; P=0.02) as well as a lower MCE score index (0.65±0.38 versus 0.89±0.21; P < 0.02). Conclusions Postp rocedu ral cTnI elevation in high risk patients with NSTE ACS is associated with an a bnormal tissue level perfusion.
文摘Background Most patients with acute myocardial infarction (AMI) are admitted t o hospitals without percutaneous transluminal coronary angioplasty (PTCA) facili ties or are initially managed in a prehospital mobile unit. Thrombolysis remains the most readily available reperfusion treatment in those settings, but the opt imal subsequent strategy in those patients is unclear. If a mechanical recanaliz ation is likely to be performed in an emergency, it is probably desirable that t he patient receives abciximab, the glycoprotein IIb/IIIa antagonist with the str ongest evidence of benefit for angioplasty in AMI. Objective The aim of this tri al is to compare the effects on clinical outcome and cost effectiveness of 2 st rategies after immediate treatment with abciximab and half dose reteplase for S T elevation AMI: to manage the patients conservatively (referring them for resc ue PTCA only if needed) or to immediately send all patients for emergency corona ry angioplasty. Methods The Combined Abciximab RE teplase Stent Study in Acute Myocardial Infarction(CARESS in AMI) is an open, prospective, randomized,multicenter clinical trial conducted in patients with high risk ST segment elevation AMI treated within 12 hours from symptom onset in hospitals without PTCA facilities or in a prehospital mobile intensive care u nit. Apart from contraindications to thrombolysis, themain exclusion criteria ar e age ≥75 years and a past history of CABG surgery or a percutaneous coronary i ntervention procedure involving the infarct related artery. Enrollment will be performed in hospitals without PTCA facilities or directly in the ambulance if a dedicated system is in place for prehospital diagnosis and treatment of AMI. Pa tients will receive half dose reteplase and full dose abciximab and will subse quently be randomized to conventional medical therapy (with referral for emergen cy rescue PTCA allowed in selected cases) or emergency angioplasty. The primary end point is the 30-day combined incidence of mortality, reinfarction, and refr actory ischemia. In order to obtain a 95%power (2-sided) to detect a 42%reduc tion in the primary end point, 900 patients are required in each arm of the stud y. Secondary end points include the 1-year composite end point of mortality, re infarction, refractory ischemia, and hospital readmission because of heart failu re; resource use at 30 days and 1 year; and the incidence of inhospital stroke a nd bleeding complications in the 2 groups. Results Seventy four patients have b een randomized (as of March 10, 2004); results are expected in June 2005. Conclu sion This study will establish whether angioplasty must be started as soon as po ssible in all patients who receive combined pharmacologic reperfusion with the g lycoprotein IIb/IIIa inhibitor abciximab and half dose thrombolysis or whether it can be postponed or skipped in patients with signs of successful reperfusion, with obvious organizational advantages.
