Background: The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial. Methods: The CADILLAC trial randomized 2082 patients with acute...Background: The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial. Methods: The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab. Results: Earlier reperfusion(< 3 vs 3-6 vs >6 hours) was associated with lower 1-year mortality(2.6%vs 4.3%vs 4.8%, P=.046 for< 3 vs ≥3 hours), more frequent grade 2 to 3 myocardial blush(55%vs 53%vs 44%, P=.003), more frequent complete ST-segment resolution(64%vs 68%vs 47%, P=.006), and greater improvement in left ventricular function. Early reperfusion(< 3 vs 3-6 vs≥3 hours)was associated with lower mortality in high-risk patients(3.8%vs 6.9%vs 7.0%, P=.051 for< 3 vs ≥3 hours) but not in low-risk patients(1.4%vs 0.6%vs 1.0%, P=.63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms(≤2 hours, hazard ratio 1.24, P=.013) but not late(>2 hours, heart rate 0.88, P=.33). Conclusions: Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.展开更多
We determined the outcomes of patients with acute ST-segment elevation(STE) myocardial infarction(STEMI) and non-STEMI(NSTEMI) after primary percutaneous coronary intervention(PCI). The prognosis after primary PCI in ...We determined the outcomes of patients with acute ST-segment elevation(STE) myocardial infarction(STEMI) and non-STEMI(NSTEMI) after primary percutaneous coronary intervention(PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for >30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725(87.8%) and NSTEMI in 239(12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival(2.4 vs 1.8 hours, p=0.0002) and increased door-to-balloon time(3.2 vs 1.9 hours, p< 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline(37.3%vs 19.4%, p< 0.0001) and higher ejection fraction(58.7%vs 55.8%, p=0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality(3.4%vs 4.4%, p=0.40) but higher rates of major adverse cardiac events(24.0%vs 16.6%, p=0.007) that was driven by more frequent ischemic target vessel revascularization(21.8%vs 11.9%, p< 0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.展开更多
它闯进的是一个强手林立的阵营,宝马 X5.奔驰 M 级、沃尔沃XC90、路虎览胜、大众汽车途锐、保时捷卡宴等众多高手早在此恭候多时,它们各怀绝技,身手不凡。而迟到的它也并非等闲之辈,一百年辉煌的历史筑就了享誉世界的口碑,全球第一大汽...它闯进的是一个强手林立的阵营,宝马 X5.奔驰 M 级、沃尔沃XC90、路虎览胜、大众汽车途锐、保时捷卡宴等众多高手早在此恭候多时,它们各怀绝技,身手不凡。而迟到的它也并非等闲之辈,一百年辉煌的历史筑就了享誉世界的口碑,全球第一大汽车巨头的鼎力支持是它强大的后盾,而最重要的是中国上海有它惟一的海外生产基地。展开更多
Background-Biological age is a strong determinant of prognosis in patients with acute myocardial infarction(AMI). We sought to examine the impact of age after primary percutaneous coronary intervention in AMI and to d...Background-Biological age is a strong determinant of prognosis in patients with acute myocardial infarction(AMI). We sought to examine the impact of age after primary percutaneous coronary intervention in AMI and to determine whether routine coronary stent implantation and/or platelet glycoprotein IIb/IIIa inhibitors improve clinical outcomes in elderly patients after primary angioplasty. Methods and Results-In the CADILLAC trial, 2082 patients with AMI were randomized to balloon angioplasty,angioplasty plus abciximab,stenting alone, or stenting plus abciximab. No patient was excluded on the basis of advanced age; patients ranging from 21 to 95 years of age were enrolled. One-year mortality increased for each decile of age, exponentially after 65 years of age(1.6%for patients< 55 years, 2.1%for 55 to 65 years, 7.1%for 65 to 75 years, 11.1%for patients >75 years; P< 0.0001). Elderly patients also had increased rates of stroke and major bleeding compared with their younger counterparts. Among elderly patients (≥65 years), 1-year rates of ischemic target revascularization (7.0%versus 17.6%; P< 0.0001) and subacute or late thrombosis (0%versus 2.2%; P=0.005)were reducedwith stenting comparedwith balloon angioplasty. Routine abciximab administration, although safe,was not of definite benefit in elderly patients. Rates of mortality, reinfarction, disabling stroke, and major bleeding in the elderly were independent of reperfusion modality. Conclusions-Despite contemporary mechanical reperfusion strategies,mortality, major bleeding, and stroke rates remain high in elderly patients undergoing primary percutaneous coronary intervention, outcomes that are not affected by stents or glycoprotein Ⅱb/Ⅲa inhibitors. By reducing restenosis, however, stent implantation improves clinical outcomes in elderly patients with AMI.展开更多
文摘Background: The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial. Methods: The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab. Results: Earlier reperfusion(< 3 vs 3-6 vs >6 hours) was associated with lower 1-year mortality(2.6%vs 4.3%vs 4.8%, P=.046 for< 3 vs ≥3 hours), more frequent grade 2 to 3 myocardial blush(55%vs 53%vs 44%, P=.003), more frequent complete ST-segment resolution(64%vs 68%vs 47%, P=.006), and greater improvement in left ventricular function. Early reperfusion(< 3 vs 3-6 vs≥3 hours)was associated with lower mortality in high-risk patients(3.8%vs 6.9%vs 7.0%, P=.051 for< 3 vs ≥3 hours) but not in low-risk patients(1.4%vs 0.6%vs 1.0%, P=.63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms(≤2 hours, hazard ratio 1.24, P=.013) but not late(>2 hours, heart rate 0.88, P=.33). Conclusions: Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.
文摘We determined the outcomes of patients with acute ST-segment elevation(STE) myocardial infarction(STEMI) and non-STEMI(NSTEMI) after primary percutaneous coronary intervention(PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for >30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725(87.8%) and NSTEMI in 239(12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival(2.4 vs 1.8 hours, p=0.0002) and increased door-to-balloon time(3.2 vs 1.9 hours, p< 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline(37.3%vs 19.4%, p< 0.0001) and higher ejection fraction(58.7%vs 55.8%, p=0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality(3.4%vs 4.4%, p=0.40) but higher rates of major adverse cardiac events(24.0%vs 16.6%, p=0.007) that was driven by more frequent ischemic target vessel revascularization(21.8%vs 11.9%, p< 0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.
文摘它闯进的是一个强手林立的阵营,宝马 X5.奔驰 M 级、沃尔沃XC90、路虎览胜、大众汽车途锐、保时捷卡宴等众多高手早在此恭候多时,它们各怀绝技,身手不凡。而迟到的它也并非等闲之辈,一百年辉煌的历史筑就了享誉世界的口碑,全球第一大汽车巨头的鼎力支持是它强大的后盾,而最重要的是中国上海有它惟一的海外生产基地。
文摘Background-Biological age is a strong determinant of prognosis in patients with acute myocardial infarction(AMI). We sought to examine the impact of age after primary percutaneous coronary intervention in AMI and to determine whether routine coronary stent implantation and/or platelet glycoprotein IIb/IIIa inhibitors improve clinical outcomes in elderly patients after primary angioplasty. Methods and Results-In the CADILLAC trial, 2082 patients with AMI were randomized to balloon angioplasty,angioplasty plus abciximab,stenting alone, or stenting plus abciximab. No patient was excluded on the basis of advanced age; patients ranging from 21 to 95 years of age were enrolled. One-year mortality increased for each decile of age, exponentially after 65 years of age(1.6%for patients< 55 years, 2.1%for 55 to 65 years, 7.1%for 65 to 75 years, 11.1%for patients >75 years; P< 0.0001). Elderly patients also had increased rates of stroke and major bleeding compared with their younger counterparts. Among elderly patients (≥65 years), 1-year rates of ischemic target revascularization (7.0%versus 17.6%; P< 0.0001) and subacute or late thrombosis (0%versus 2.2%; P=0.005)were reducedwith stenting comparedwith balloon angioplasty. Routine abciximab administration, although safe,was not of definite benefit in elderly patients. Rates of mortality, reinfarction, disabling stroke, and major bleeding in the elderly were independent of reperfusion modality. Conclusions-Despite contemporary mechanical reperfusion strategies,mortality, major bleeding, and stroke rates remain high in elderly patients undergoing primary percutaneous coronary intervention, outcomes that are not affected by stents or glycoprotein Ⅱb/Ⅲa inhibitors. By reducing restenosis, however, stent implantation improves clinical outcomes in elderly patients with AMI.
