Novel classification of gastric polyps:The good,the bad and the ugly

Gastric polyps(GPs)are increasingly common.On upper endoscopy,they should be examined with white light and occasionally chromoendoscopy,and their morphology classified according to the Paris classification.Most GPs have a typical endoscopic appearance and can be associated with diseases like Helicobacter pylori infection.Histological examination is necessary for an accurate diagnosis.While most polyps are non-neoplastic and do not require treatment,some carry a risk of malignancy or are already malignant.Therefore,understanding the diagnosis,classification,and management of GPs is crucial for patient prognostication.Our new classification categorizes GPs into"good","bad",and"ugly"based on their likelihood of becoming malignant.We aim to provide descriptions of the endoscopic appearance,pathology,treatment,and follow-up for different GPs,as well as clinical management flowcharts.

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas:Basic principles and recommendations

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery.They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat.These two related conditions must be distinguished and characterized to guide the appropriate treatment.Leak is defined as a transmural defect with communication between the intra and extraluminal compartments,while fistula is defined as an abnormal communication between two epithelialized surfaces.Traditionally,surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates.However,with the development of novel devices and techniques,endoscopic therapy plays an increasingly essential role in managing these conditions.Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas.Several endoscopic techniques are available with different mechanisms of action,including direct closure,covering/diverting or draining.The treatment should be individualized by considering the characteristics of both the patient and the defect.Although there is a lack of high-quality studies to provide standardized treatment algorithms,this narrative review aims to provide a summary of the current scientific evidence and,based on this data and our extensive experience,make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

Heart rate response and recovery during exercise predict future delirium risk——A prospective cohort study in middle-to older-aged adults

Background:Delirium is a neurocognitive disorder characterized by an abrupt decline in attention,awareness,and cognition after surgical/illness-induced stressors on the brain.There is now an increasing focus on how cardiovascular health interacts with neurocognitive disorders given their overlapping risk factors and links to subsequent dementia and mortality.One common indicator for cardiovascular health is the heart rate response/recovery(HRR)to exercise,but how this relates to future delirium is unknown.Methods:Electrocardiogram data were examined in 38,740 middle-to older-aged UK Biobank participants(mean age=58.1 years,range:40-72 years;47.3%males)who completed a standardized submaximal exercise stress test(15-s baseline,6-min exercise,and 1-min recovery)and required hospitalization during follow-up.An HRR index was derived as the product of the heart rate(HR)responses during exercise(peak/resting HRs)and recovery(peak/recovery HRs)and categorized into low/average/high groups as the bottom quartile/middle 2 quartiles/top quartile,respectively.Associations between 3 HRR groups and new-onset delirium were investigated using Cox proportional hazards models and a2-year landmark analysis to minimize reverse causation.Sociodemographic factors,lifestyle factors/physical activity,cardiovascular risk,comorbidities,cognition,and maximal workload achieved were included as covariates.Results:During a median follow-up period of 11 years,348 participants(9/1000)newly developed delirium.Compared with the high HRR group(16/1000),the risk for delirium was almost doubled in those with low HRR(hazard ratio=1.90,95%)confidence interval(95%CI):1.30-2.79,p=0.001)and average HRR(hazard ratio=1.54,95%CI:1.07-2.22,p=0.020)).Low HRR was equivalent to being 6 years older,a current smoker,or>3 additional cardiovascular disease risks.Results were robust in sensitivity analysis,but the risk appeared larger in those with better cognition and when only postoperative delirium was considered(n=147;hazard ratio=2.66,95%CI:1.46-4.85,p=0.001).Conclusion:HRR during submaximal exercise is associated with future risk for delirium.Given that HRR is potentially modifiable,it may prove useful for neurological risk stratification alongside traditional cardiovascular risk factors.

The efficacy of vitamin E in preventing arthrofibrosis after joint replacement

Background:Arthrofibrosis is a joint disorder characterized by excessive scar formation in the joint tissues.Vitamin E is an antioxidant with potential anti-fibroblastic effect.The aim of this study was to establish an arthrofibrosis rat model after joint replacement and assess the effects of vitamin E supplementation on joint fibrosis.Methods:We simulated knee replacement in 16 male Sprague–Dawley rats.We immobilized the surgical leg with a suture in full flexion.The control groups were killed at 2 and 12 weeks(n=5 per group),and the test group was supplemented daily with vitamin E(0.2 mg/mL)in their drinking water for 12 weeks(n=6).We performed histological staining to investigate the presence and severity of arthrofibrosis.Immunofluorescent staining andα2-macroglobulin(α2M)enzyme-linked immunosorbent assay(ELISA)were used to assess local and systemic inflammation.Static weight bearing(total internal reflection)and range of motion(ROM)were collected for functional assessment.Results:The ROM and weight-bearing symmetry decreased after the procedure and recovered slowly with still significant deficit at the end of the study for both groups.Histological analysis confirmed fibrosis in both lateral and posterior periarticular tissue.Vitamin E supplementation showed a moderate anti-inflammatory effect on the local and systemic levels.The vitamin E group exhibited significant improvement in ROM and weight-bearing symmetry at day 84 compared to the control group.Conclusions:This model is viable for simulating arthrofibrosis after joint replacement.Vitamin E may benefit postsurgical arthrofibrosis,and further studies are needed for dosing requirements.

Updates in diagnosis and management of pancreatic cysts

Incidental pancreatic cysts are commonly encountered with some cysts having malignant potential.The most common pancreatic cystic neoplasms include serous cystadenoma,mucinous cystic neoplasm and intraductal papillary mucinous neoplasm.Risk stratifying pancreatic cysts is important in deciding whether patients may benefit from endoscopic ultrasound(EUS)or surgical resection.Surgery should be reserved for patients with malignant cysts or cysts at high risk for developing malignancy as suggested by various risk features including solid mass,nodule and dilated main pancreatic duct.EUS may supplement magnetic resonance imaging findings for cysts that remain indeterminate or have concerning features on imaging.Various cyst fluid markers including carcinoembryonic antigen,glucose,amylase,cytology,and DNA markers help distinguish mucinous from nonmucinous cysts.This review will guide the practicing gastroenterologist in how to evaluate incidental pancreatic cysts and when to consider referral for EUS or surgery.For presumed low risk cysts,surveillance strategies will be discussed.Managing pancreatic cysts requires an individualized approach that is directed by the various guidelines.

Cross-regulation of the Nanog and Cdx2 promoters

The first cell fate choice in the mammalian embryo, the segregation of the inner cell mass （ICM） and trophectoderm （TE）, is regulated by the mutually antagonistic effects of the transcription factors, Oct4 and Cdx2, while the pluripotency factor, Nanog, is essential to specify the epiblast. We have analyzed the promoters of Nanog and Cdx2, and have found that these two transcription factors are likewise regulated reciprocally. Using an embryonic stem cell line with conditional TE differentiation, we show that Nanog overexpression suppresses the upregulation of TE markers, while Nanog knockdown upregulates the expression of TE markers. We further show that Nanog and Cdx2 bind to and repress each other＇s promoters. However, whereas Nanog knockout results in detectable Cdx2 expression in the ICM, we observe no overt disruption of blastocyst development, indicating that Nanog plays a subservient role to Oct4 in segregation of the ICM and TE.

Angiographic and clinical outcomes in elderly subjects treated with percutaneous coronary intervention following fibrinolytic administration for ST-elevation myocardial infarction

Background Prior studies have demonstrated that the achievement of faster coronary artery flow following reperfusion therapies is associated with improved outcomes among ST-elevation myocardial infarction (STEMI) patients. The association of patient age with angiographic characteristics of flow and perfusion after rescue/adjunctive percutaneous coronary intervention (PCI) following the administration of fibrinolytic therapy has not been previously investigated. Objectives and Methods We examined the association between age (≥ 70 years or ＜ 70years)and clinical and angiographic outcomes in 1472 STEMI patients who underwent rescue/adjunctive PCI following fibrinolytic therapy in 7 TIMI trials. We hypothesized that elderly patients would have slower post-PCI epicardial flow and worsened outcomes compared to younger patients. Results The 218 patients aged ≥ 70 years (14.8%) had more comorbidities than younger patients. Although these patients had significant angiographic improvement in TIMI frame counts and rates of TIMI Grade 3 flow following rescue/adjunctive PCI, elderly patients had higher (slower)post-PCI TIMI frame counts compared to the younger cohort (25 vs 22 frames, P = 0.039), and less often achieved post-PCI TIMI Grade 3 flow (80.1 vs 86.4%, P = 0.017). The association between age ( ≥70 years) and slower post-PCI flow was independent of gender, time to treatment, left anterior descending (LAD) lesion location, and pulse and blood pressure on admission. Elderly patients also had 4-fold higher mortality at 30 days (12.0 vs 2.7%,P = 0. 001 ). Conclusions This study suggests one possible mechanism underlying worsened outcomes among elderly STEMI patients insofar as advanced chronological age was associated with higher TIMI frame counts and less frequent TIMI Grade 3 flow after rescue/adjunctive PCI.

Biliary drainage in inoperable malignant biliary distal obstruction: A systematic review and meta-analysis

BACKGROUND Endoscopic drainage remains the treatment of choice for unresectable or inoperable malignant distal biliary obstruction(MDBO).AIM To compare the safety and efficacy of plastic stent(PS)vs self-expanding metal stent(SEMS)placement for treatment of MDBO.METHODS This meta-analysis was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.A comprehensive search was performed in MEDLINE,Cochrane,Embase,Latin American and Caribbean Health Sciences Literature,and grey literature to identify randomized clinical trials(RCTs)comparing clinical success,adverse events,stent dysfunction rate,reintervention rate,duration of stent patency,and mean survival.Risk difference(RD)and mean difference(MD)were calculated and heterogeneity was assessed with I2 statistic.Subgroup analyses were performed by SEMS type.RESULTS Twelve RCTs were included in this study,totaling 1005 patients.There was no difference in clinical success(RD=-0.03,95%confidence interval[CI]:-0.01,0.07;I 2=0%),rate of adverse events(RD=-0.03,95%CI:-0.10,0.03;I2=57%),and mean patient survival(MD=-0.63,95%CI:-18.07,19.33;I2=54%)between SEMS vs PS placement.However,SEMS placement was associated with a lower rate of reintervention(RD=-0.34,95%CI:-0.46,-0.22;I2=57%)and longer duration of stent patency(MD=125.77 d,95%CI:77.5,174.01).Subgroup analyses revealed both covered and uncovered SEMS improved stent patency compared to PS(RD=152.25,95%CI:37.42,267.07;I2=98%and RD=101.5,95%CI:38.91,164.09;I2=98%;respectively).Stent dysfunction was higher in the covered SEMS group(RD=-0.21,95%CI:-0.32,-0.1;I²=205%),with no difference in the uncovered SEMS group(RD=-0.08,95%CI:-0.56,0.39;I²=87%).CONCLUSION While both stent types possessed a similar clinical success rate,complication rate,and patient-associated mean survival for treatment of MDBO,SEMS were associated with a longer duration of stent patency compared to PS.

Magnetic resonance imaging appearance and changes on intracavitary Gliadel wafer placement:A pilot study

AIM:To investigate changes on magnetic resonance imaging(MRI) which occur with intracavitary Gliadel wafer placement in patients with glioblastoma multiforme(GBM).METHODS:This retrospective Health Insurance Portability and Accountability Act-compliant study was approved by the institutional review board,with a waiver of informed consent.A total of eight patients aged 29-67 years with GBM underwent Gliadel wafer placement.T2-weighted/FLAIR images and post-contrast T1-weighted images both before and after wafer placement were retrospectively reviewed in consensus to determine changes in the following parameters:appearance of the pericavitary tissue,pattern of tumor recurrence or progression and appearance of the Gliade lwafer itself.RESULTS:Five out of the eight patients had a progressive increase in enhancement and pericavitary T2/FLAIR hyperintensity within the first 2 mo and a subsequent decrease in these MRI findings.None ofthese patients had tumor recurrence within the first6 mo.Three out of the eight patients demonstrated aprogressive increase in enhancement and pericavitary T2 hyperintensity,which continued after the first 6 mo,and were subsequently diagnosed with true tumor progression.There was no increase in distant/nonlocal tumor recurrence.The Gliadel wafer appearance changed over time.CONCLUSION:Pseudoprogression is common after intracavitary Gliadel wafer placement and thus care should be taken before diagnosing tumor progression or recurrence within the first 2 mo.

Ineffective esophageal motility is associated with acute rejection after lung transplantation independent of gastroesophageal reflux

BACKGROUND Gastroesophageal reflux is associated with poorer outcomes after lung transplant,likely through recurrent aspiration and allograft injury.Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes,the role of esophageal manometry in the assessment of lung transplant patients remains debated,and the impact of esophageal dysmotility on transplant outcomes is unclear.Of particular interest is ineffective esophageal motility(IEM)and its associated impact on esophageal clearance.AIM To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation.METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018.Patients with pre-transplant anti-reflux surgery were excluded.Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing.Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection,defined histologically per International Society of Heart and Lung Transplantation guidelines.Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery,last clinic visit,or death.Fisher’s exact test for binary variables and student’s t-test for continuous variables were performed to assess for differences between groups.RESULTS Of 184 subjects(54%men,mean age:58,follow-up:443 person-years)met criteria for inclusion.Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis(41%).During the follow-up period,60 subjects(33.5%)developed acute rejection.The all-cause mortality was 16.3%.Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection[hazard ratio(HR):1.984,95%CI:1.03-3.30,P=0.04],confirmed on Kaplan-Meier curve.On multivariable analysis,IEM remained independently associated with acute rejection,even after controlling for potential confounders such as the presence of acid and nonacid reflux(HR:2.20,95%CI:1.18-4.11,P=0.01).Nonacid reflux was also independently associated with acute rejection on both univariate(HR:2.16,95%CI:1.26-3.72,P=0.005)and multivariable analyses(HR:2.10,95%CI:1.21-3.64,P=0.009),adjusting for the presence of IEM.CONCLUSION Pre-transplant IEM was associated with acute rejection after transplantation,even after controlling for acid and nonacid reflux.Esophageal motility testing may be considered in lung transplant to predict outcomes.

Outcomes of Medicare beneficiaries hospitalised with transient ischaemic attack and stratification using the ABCD^(2) score

Background Long-term outcomes for Medicare beneficiaries hospitalised with transient ischaemic attack(TIA)and role of ABCD^(2) score in identifying high-risk individuals are not studied.Methods We identified 40825 Medicare beneficiaries hospitalised from 2011 to 2014 for a TIA to a Get With The Guidelines(GWTG)-Stroke hospital and classified them using ABCD^(2)s of mortality and rehospitalisation(all-cause,ischaemic stroke,haemorrhagic stroke,myocardial infarction,and gastrointestinal and intracranial haemorrhage)for high-risk versus low-risk groups adjusted for patient and hospital characteristics.Results Of the 40825 patients,35118(86%)were high risk(ABCD^(2)≥4)and 5707(14%)were low risk(ABCD^(2)=0-3).Overall rate of mortality during 1-year follow-up after hospital discharge for the index TIA was 11.7%,44.3% were rehospitalised for any reason and 3.6%were readmitted due to stroke.Patients with ABCD^(2) score≥4 had higher mortality at 1 year than not(adjusted HR 1.18,95%CI 1.07 to 1.30).Adjusted risks for ischaemic stroke,all-cause readmission and mortality/all-cause readmission at 1 year were also significantly higher for patients with ABCD^(2) score≥4 vs 0-3.In contrast,haemorrhagic stroke,myocardial infarction,gastrointestinal bleeding and intracranial haemorrhage risk were not significantly different by ABCD^(2) score.Conclusions This study validates the use of ABCD^(2) score for long-term risk assessment after TIA in patients aged 65 years and older.Attentive efforts for community-based follow-up care after TIA are needed for ongoing prevention in Medicare beneficiaries who were hospitalised for TIA.

Molecular basis of the first cell fate determination in mouse embryogenesis

Through proliferation and differentiation, a single cell, the zygote, can give rise to a complex organism composed of many types of cells. Up to the eight-cell embryo stage, the blastomeres are morphologically identical and distributed symmetrically in the mammalian embryo. Functionally, in some species, they are all totipotent. However, due to the compaction of blastomeres and the asymmetrical cell division at the late phase of the eight-cell embryo, the blastomeres of the morula are no longer identical. During the transition from morula to blastocyst, blastomeres differentiate, resulting in the first cell fate decision in embryogenesis, namely, the segregation of the inner cell mass and the tropheetoderm. In this review, we will discuss the regulatory mechanisms essential for the cell fate choice during blastocyst development, including transcriptional regulation, epigenetic regulation, mieroRNAs, and signal transduction.

Evaluation of Different Strategies for Prevention of Venous Thromboembolism in Elective Orthopedic Surgery

Our objective is to evaluate different pharmacologic strategies for VTE （venous thromboembolism） prophylaxis following orthopedic surgery at a tertiary academic medical center. This was a retrospective, observational study assessing the efficacy and safety of different strategies for VTE prophylaxis in elective total knee arthroplasty and total hip arthroplasty surgery patients. We evaluated warfarin at two different INR （international normalized ratio） goal ranges （1.5-2.5 and 1.8-2.3） and aspirin 325 mg once or twice daily. The main efficacy outcome was a composite of symptomatic deep vein thrombosis or pulmonary embolism. The main safety outcome was incidence of major or minor bleeding. From January 2010 to June 2010, there were 190 patients in the warfarin group with INR range 1.5-2.5, 214 patients in the warfarin group with INR range 1.8-2.3, and 48 patients in the aspirin group. Of the three strategies, two primary events occurred in each of the warfarin groups （1.6% vs. 1.4%; P = 0.31）. There were no primary events in the aspirin group. Rates of major or minor bleeding were 4.2% in warfarin group INR 1.5-2.5 and 4.7% in warfarin group 1NR 1.8-2.3 （P = 0.19）, and 2.1% in the aspirin arm （P = 0.29）. There were no differences in the incidence of VTE in any of the treatment arms.

What do the recent American Heart Association/American College of Cardiology Foundation Clinical Practice Guidelines tell us about the evolving management of coronary heart disease in older adults?

Biological aging predisposes older adults to increased cardiovascular disease (CHD) and greater disease complexity. Given the high age-related prevalence of CHDand age-related compounding factors, the recently updatedAmerican HeartAssociation/American College of Cardiology Foundation CHD-related guidelines increased their focus on older patients. These guidelines are predominately evidence-based (using data from quality randomized clinical trials) and are organized to delineate medications and procedures that best treat particular cardiovascular diseases.While such rationale and thought work well in young and middle aged adults, they become problematic in patientswho are very old. Data pertaining to adults aged ≥80 are virtually absent from most randomized clinical trials, and even in the instances when very old patients were included, eligibility criteria typically excluded candidates with co-morbidities and complexities of customary CHD patients. While medications and interventions yielding benefit in clinical trials should theoretically produce the greatest benefits for patients with high intrinsic risk, age-related cardiovascular complexities also increase iatrogenic risks. Navigating between the potential for high benefit and high risk in “evidence-based”cardiovascular management remains a key Geriatric Cardiology challenge. In this review we consider the expanded Geriatric Cardiology content of current guidelines, acknowledging both the progress that has been made, as well as the work that still needs to be accomplished to truly address the patient-centered priorities of older CHDpatients.

Vulvar infl ammation as a manifestation of Crohn＇s disease

Crohn＇s disease is a chronic inflammatory boweldisease that is also associated with extra-intestinal complications, such as arthritis, erythema nodosum,deep venous thrombosis, and uveitis. Involvement of thevulva, however, is a rare fi nding in female patients withCrohn＇s disease. We present a case of vulvar Crohn＇sdisease and discuss the disease process and treatmentoptions for affected patients.

ST段抬高型心肌梗死患者行直接经皮冠状动脉介入术前依替巴肽的急诊早期使用:TITAN(急性心肌梗死患者中至应用依替巴肽治疗时间)-TIMI34试验的结果

背景:ST段抬高型心肌梗死(STEMI)患者行直接经皮冠状动脉介入(PCI)术前心外膜血流的早期恢复常伴有较好的临床预后。方法:设想,与在心脏导管室(CCL)行诊断性血管造影后使用血小板糖蛋白IIb/IIIa受体拮抗剂依替巴肽相比较,行PCI术前在急诊科(ED)早期使用依替巴肽可获得更好的心外膜血流和心肌灌注。343例STEMI患者被随机分为两组,分别于ED早期(n=180)或CCL(n=163)应用依替巴肽。

比较应用裸金属支架与药物洗脱支架行经皮冠状动脉介入治疗非ST段抬高型急性冠状动脉综合征对生物标记物水平的影响

Drug-eluting stents(DESs) deliver biphasic(early and late)-elution of anti-inflammatory compounds. We therefore hypothesized that DESs would be associated with early reductions in inflammatory biomarker release after percutaneous coronary intervention(PCI). A total of 741 patients with non-ST-elevation acute coronary syndrome underwent PCI in the Randomized Trial to Evaluate the Relative PROTECTion against Post-PCI Microvascular Dysfunction and Post-PCI Ischemia among Anti-Platelet and Anti-Thrombotic Agents(PROTECT) Thrombolysis In Myocardial Infarction 30 study of eptifibatide and reduced-dose antithrombin compared with bivalirudin. Serial biomarkers C-reactive protein, troponin, creatine kinase-MB, soluble CD40 ligand, interleukin-6, prothrombin fragment F1.2, and RANTES(regulated on activation, normal T-cell expressed and secreted) were assessed through 24 hours after PCI. DES use was at the investigator’s discretion. Patients treated with DESs(n=665) versus bare metal stents(n=139) were more likely to have patent arteries before PCI(92.0%vs 86.6%, p=0.04), Thrombolysis In Myocardial Infarction myocardial perfusion grade 3(57.9%vs 47.7%, p=0.033), and the left anterior descending artery as the culprit artery(38.5%vs 18.3%, p< 0.001). The increase in C-reactive protein and troponin was lower among patients undergoing DES implantation(median 2.1 vs 3.5 mg/L for C-reactive protein, median 0.11 vs 0.41 ng/ml for troponin), even after adjustment for randomized treatment, clopidogrel before treatment, diabetes mellitus status, epicardial patency, left anterior descending artery location, and myocardial perfusion(p=0.036 and p=0.039, respectively). Interleukin-6 was lower with DESs on univariate analysis but not multivariate analysis. Creatine kinase-MB, soluble sCD40 ligand, prothrombin fragment F1.2, and RANTES did not differ by DES use. In conclusion, patients undergoing DES implantation achieved more reductions in periprocedural markers of inflammation and necrosis than patients receiving bare metal stents among those with non-ST-elevation acute coronary syndrome.

80岁以上老人接受植入式除颤器后的生存率分析

背景:尽管许多临床试验已经扩展了植入式除颤器(ICD)的适应证,但是在这些研究中很少入选80岁以上的老人。总之,该亚组的生存率尚不明确。方法:对1995年7月和2003年9月之间接受ICD植入且当时年龄≥80岁的患者进行了回顾性分析。

氯吡格雷在ST段抬高型心肌梗死溶栓后早期和持续动脉开放中的作用:ECG CLARITY-TIMI28研究

Objectives: This study was designed to determine the relationship between clopidogrel and early ST-segment resolution(STRes) and the interaction of the two with clinical outcomes after fibrinolysis. Background: ST-segment resolution is an early noninvasive marker of coronary reperfusion. Methods: The CLARITY-TIMI 28(Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28) trial randomized 3,491 patients with ST-segment elevation myocardial infarction(STEMI) undergoing fibrinolysis to clopidogrel versus placebo. ST-segment resolution was defined as complete(>70%), partial(30%to 70%), or none(< 30%). Results: Electrocardiograms were valid for interpretation in 2,431 patients at 90 min and 2,087 at 180 min. There was no difference in the rate of complete STRes between the clopidogrel and placebo groups at 90 min(38.4%vs. 36.6%at 90 min). When patients were stratified by STRes category, treatment with clopidogrel resulted in greater benefit among those with evidence of early STRes, with greater odds of an open artery at late angiography in patients with partial(odds ratio[OR] 1.4, p=0.04) or complete(OR 2.0, p< 0.001) STRes, but no improvement in those with no STRes at 90 min(OR 0.89, p=0.48)(p for interaction=0.003). Clopidogrel was also associated with a significant reduction in the odds of an in-hospital death or myocardial infarction in patients who achieved partial(OR 0.30, p=0.003) or complete STRes at 90 min(OR 0.49, p=0.056), whereas clinical benefit was not apparent in patients who had no STRes(OR 0.98, p=0.95)(p for interaction=0.027). By 30 days, the clinical benefit of clopidogrel was predominately seen in patients with complete STRes. Conclusions: Clopidogrel appears to improve late coronary patency and clinical outcomes by preventing reocclusion of open arteries rather than by facilitating early reperfusion.

ST段抬高型心肌梗死的整体结局:ExTRACT-TIMI25注册研究和试验研究

背景:除了区域差异之外,ST段抬高型心肌梗死(STEMI)患者的结局在临床试验和常规实践中也有不同。假设对基线风险进行校正能够将这种差异最小化。方法:ExTRACT-TIMI(依诺肝素与溶栓再灌注治疗急性心肌梗死:心肌梗死溶栓)