Background Tumor necrosis factor alpha- α (TNF- α ) activation is an independent prognostic indicator of mortality in patients with heart failure(HF). Despite the recognition that several TNF family cytokines are el...Background Tumor necrosis factor alpha- α (TNF- α ) activation is an independent prognostic indicator of mortality in patients with heart failure(HF). Despite the recognition that several TNF family cytokines are elevated during myocardial infarction, their role in predicting subsequent prognosis in these setting remains poorly understood. Methods and Results We performed a systematic evaluation of TNF- α and its type 1 and 2 soluble receptors, together with interleukin(IL)- 6, IL- 1 receptor antagonist, and IL- 10, in 184 patients(132 men; mean age, 64± 12) consecutively admitted for myocardial infarction. We correlated their values to short and long- term incidence of death and HF(primary outcome). In 10 patients, we also studied the presence of transcardiac gradients for TNF- α and its soluble receptors. The control group comprised 45 healthy subjects who were sex and age matched(33 men; mean age, 65± 6 years) to the patients. All tested cytokines were increased in patients, and no transcardiac or systemic AV difference was found. After a median follow- up of 406 days(range, 346 to 696 days), 24 patients died and 32 developed HF. Univariate analysis showed that all cytokines were related to outcome, whereas after adjustment for baseline and clinical characteristics, sTNFR- 1 remained the only independent predictor of death and HF(hazard ratio, 2.9; 95% CI, 1.9 to 3.8, tertile 1 versus 3), together with left ventricular ejection fraction, Killip class, and creatine kinase- MB at peak. Conclusions sTNFR- 1 is a major short and long- term predictor of mortality and HF in patients with acute myocardial infarction.展开更多
Bare-metal stenting with abciximab pretreatment is currently considered a reasonable reperfusion strategy for acute ST-segment elevation myocardial infarction(STEMI). Sirolimus-eluting stents significantly reduce the ...Bare-metal stenting with abciximab pretreatment is currently considered a reasonable reperfusion strategy for acute ST-segment elevation myocardial infarction(STEMI). Sirolimus-eluting stents significantly reduce the need for target-vessel revascularization(TVR)vs bare-metal stents but substantially increase procedural costs. At current European list prices, the use of tirofiban instead of abciximab would absorb the difference in cost between stenting with sirolimus-eluting vs bare-metal stents. Abstract: To evaluate the clinical and angiographic impact of single high-dose bolus tirofiban plus sirolimus-eluting stenting vs abciximab plus bare-metal stenting in patients with STEMI. Design, Setting, and Patients: Prospective, single-blind, randomized controlled study(Single High Dose Bolus Tirofiban and Sirolimus Eluting Stent vs Abciximab and Bare Metal Stent in Myocardial Infarction[STRATEGY]) of 175 patients(median age, 63[interquartile range, 55- 72] years) presenting to a single referral center in Italy with STEMI or presumed new left bundle-branch block and randomized between March 6, 2003, and April 23, 2004. Intervention: Single high-dose bolus tirofiban regimen plus sirolimus-eluting stenting(n=87) vs standard-dose abciximab plus bare-metal stenting(n=88). Main Outcome Measures: The primary end point was a composite of death, non-fatal myocardial infarction, stroke, or binary restenosis at 8 months. Secondary outcomes included freedom, at day 30 and month 8, from major cardiac or cerebrovascular adverse events(composite of death, reinfarction, stroke, and repeat TVR). Results: Cumulatively, 14 of 74 patients(19% ; 95% confidence interval[CI], 10% - 28% ) in the tirofiban plus sirolimus-eluting stent group and 37 of 74 patients(50% ; 95% CI, 44% - 56% ) in the abciximab plus bare-metal stent group reached the primary end point(hazard ratio, 0.33; 95% CI, 0.18- 0.60; P< .001[P< .001 by Fischer exact test]). The cumulative incidence of death, reinfarction, stroke, or TVR was significantly lower in the tirofiban plus sirolimus-eluting stent group(18% ) vs the abciximab plus bare-metal stent group(32% )(hazard ratio, 0.53; 95% CI, 0.28- 0.92; P=.04), predominantly reflecting a reduction in the need for TVR. Binary restenosis was present in 6 of 67(9% ; 95% CI, 2% - 16% ) and 24 of 66(36% ; 95% CI, 26% - 46% ) patients in the tirofiban plus sirolimus-eluting stent and abciximab plus bare-metal stent groups, respectively(P=.002). Conclusion: Tirofiban-supported sirolimus-eluting stenting of infarcted arteries holds promise for improving outcomes while limiting health care expenditure in patients with myocardial infarction undergoing primary intervention.展开更多
文摘Background Tumor necrosis factor alpha- α (TNF- α ) activation is an independent prognostic indicator of mortality in patients with heart failure(HF). Despite the recognition that several TNF family cytokines are elevated during myocardial infarction, their role in predicting subsequent prognosis in these setting remains poorly understood. Methods and Results We performed a systematic evaluation of TNF- α and its type 1 and 2 soluble receptors, together with interleukin(IL)- 6, IL- 1 receptor antagonist, and IL- 10, in 184 patients(132 men; mean age, 64± 12) consecutively admitted for myocardial infarction. We correlated their values to short and long- term incidence of death and HF(primary outcome). In 10 patients, we also studied the presence of transcardiac gradients for TNF- α and its soluble receptors. The control group comprised 45 healthy subjects who were sex and age matched(33 men; mean age, 65± 6 years) to the patients. All tested cytokines were increased in patients, and no transcardiac or systemic AV difference was found. After a median follow- up of 406 days(range, 346 to 696 days), 24 patients died and 32 developed HF. Univariate analysis showed that all cytokines were related to outcome, whereas after adjustment for baseline and clinical characteristics, sTNFR- 1 remained the only independent predictor of death and HF(hazard ratio, 2.9; 95% CI, 1.9 to 3.8, tertile 1 versus 3), together with left ventricular ejection fraction, Killip class, and creatine kinase- MB at peak. Conclusions sTNFR- 1 is a major short and long- term predictor of mortality and HF in patients with acute myocardial infarction.
文摘Bare-metal stenting with abciximab pretreatment is currently considered a reasonable reperfusion strategy for acute ST-segment elevation myocardial infarction(STEMI). Sirolimus-eluting stents significantly reduce the need for target-vessel revascularization(TVR)vs bare-metal stents but substantially increase procedural costs. At current European list prices, the use of tirofiban instead of abciximab would absorb the difference in cost between stenting with sirolimus-eluting vs bare-metal stents. Abstract: To evaluate the clinical and angiographic impact of single high-dose bolus tirofiban plus sirolimus-eluting stenting vs abciximab plus bare-metal stenting in patients with STEMI. Design, Setting, and Patients: Prospective, single-blind, randomized controlled study(Single High Dose Bolus Tirofiban and Sirolimus Eluting Stent vs Abciximab and Bare Metal Stent in Myocardial Infarction[STRATEGY]) of 175 patients(median age, 63[interquartile range, 55- 72] years) presenting to a single referral center in Italy with STEMI or presumed new left bundle-branch block and randomized between March 6, 2003, and April 23, 2004. Intervention: Single high-dose bolus tirofiban regimen plus sirolimus-eluting stenting(n=87) vs standard-dose abciximab plus bare-metal stenting(n=88). Main Outcome Measures: The primary end point was a composite of death, non-fatal myocardial infarction, stroke, or binary restenosis at 8 months. Secondary outcomes included freedom, at day 30 and month 8, from major cardiac or cerebrovascular adverse events(composite of death, reinfarction, stroke, and repeat TVR). Results: Cumulatively, 14 of 74 patients(19% ; 95% confidence interval[CI], 10% - 28% ) in the tirofiban plus sirolimus-eluting stent group and 37 of 74 patients(50% ; 95% CI, 44% - 56% ) in the abciximab plus bare-metal stent group reached the primary end point(hazard ratio, 0.33; 95% CI, 0.18- 0.60; P< .001[P< .001 by Fischer exact test]). The cumulative incidence of death, reinfarction, stroke, or TVR was significantly lower in the tirofiban plus sirolimus-eluting stent group(18% ) vs the abciximab plus bare-metal stent group(32% )(hazard ratio, 0.53; 95% CI, 0.28- 0.92; P=.04), predominantly reflecting a reduction in the need for TVR. Binary restenosis was present in 6 of 67(9% ; 95% CI, 2% - 16% ) and 24 of 66(36% ; 95% CI, 26% - 46% ) patients in the tirofiban plus sirolimus-eluting stent and abciximab plus bare-metal stent groups, respectively(P=.002). Conclusion: Tirofiban-supported sirolimus-eluting stenting of infarcted arteries holds promise for improving outcomes while limiting health care expenditure in patients with myocardial infarction undergoing primary intervention.
