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Eitel I, Saraei R, Jurczyk D, Fach A, Hambrecht R, Wienbergen H, Frerker C, Schmidt T, Allali A, Joost A, Marquetand C, Kurz T, Haaf P, Fahrni G, Mueller C, Desch S, Thiele H, Stiermaier T. Glycoprotein IIb/IIIa inhibitors in acute myocardial infarction and angiographic microvascular obstruction: the REVERSE-FLOW trial. Eur Heart J 2024; 45:5058-5067. [PMID: 39217605 DOI: 10.1093/eurheartj/ehae587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 06/05/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND AND AIMS Glycoprotein (GP) IIb/IIIa inhibitors are recommended in acute myocardial infarction (AMI) for bailout treatment in case of angiographic microvascular obstruction (MVO), also termed no-reflow phenomenon, after percutaneous coronary intervention (PCI) with, however, lacking evidence (class IIa, level C). METHODS The investigator-initiated, international, multicentre REVERSE-FLOW trial randomized 120 patients with AMI and thrombolysis in myocardial infarction flow grade ≤ 2 after primary PCI to optimal medical therapy with or without GP IIb/IIIa inhibitor. The primary endpoint was infarct size [percentage of left ventricular (LV) mass assessed by cardiac magnetic resonance (CMR). Secondary endpoints included CMR-derived MVO and 30-day adverse clinical events. The trial is registered with ClinicalTrials.gov: NCT02739711. RESULTS The population was predominantly male (76.7%) with a median age of 66 years and ST-elevation myocardial infarction in 73.3% of patients. Clinical and angiographic characteristics were well balanced between the cohorts. Patients in the treatment group (n = 62) received eptifibatide (n = 41) or tirofiban (n = 21). Infarct size assessed by CMR imaging was similar in both study groups [25.4% of LV mass (%LV) vs. 25.2%LV; P = .386]. However, the number of patients with evidence of CMR-derived MVO (74.5% vs. 92.2%; P = .017) and the extent of MVO (2.1%LV vs. 3.4%LV; P = .025) were significantly reduced in the GP IIb/IIIa inhibitor group compared with controls. Thirty-day outcome showed an increased bleeding risk after GP IIb/IIIa inhibitor administration restricted to non-life-threatening bleedings (22.6% vs. 6.9%; P = .016) without differences in all-cause mortality (4.8% vs. 3.4%; P = .703). CONCLUSIONS Bailout GP IIb/IIIa inhibition in AMI patients with angiographic MVO failed to reduce the primary endpoint infarct size but decreased CMR-derived MVO and led to an increase in non-fatal bleeding events.
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Affiliation(s)
- Ingo Eitel
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Roza Saraei
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Dominik Jurczyk
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Andreas Fach
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Straße, 228277 Bremen, Germany
| | - Rainer Hambrecht
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Straße, 228277 Bremen, Germany
| | - Harm Wienbergen
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Straße, 228277 Bremen, Germany
| | - Christian Frerker
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Tobias Schmidt
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Abdelhakim Allali
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Alexander Joost
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Christoph Marquetand
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Thomas Kurz
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Philip Haaf
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gregor Fahrni
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Steffen Desch
- Department of Internal Medicine/Cardiology and Leipzig Heart Science, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology and Leipzig Heart Science, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Thomas Stiermaier
- Medical Clinic II, University Heart Center Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
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Rikken SAOF, van 't Hof AWJ, ten Berg JM, Kereiakes DJ, Coller BS. Critical Analysis of Thrombocytopenia Associated With Glycoprotein IIb/IIIa Inhibitors and Potential Role of Zalunfiban, a Novel Small Molecule Glycoprotein Inhibitor, in Understanding the Mechanism(s). J Am Heart Assoc 2023; 12:e031855. [PMID: 38063187 PMCID: PMC10863773 DOI: 10.1161/jaha.123.031855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Thrombocytopenia is a rare but serious complication of the intravenous glycoprotein IIb/IIIa (GPIIb/IIIa; integrin αIIbβ3) receptor inhibitors (GPIs), abciximab, eptifibatide, and tirofiban. The thrombocytopenia ranges from mild (50 000-100 000 platelets/μL), to severe (20 000 to <50 000/μL), to profound (<20 000/μL). Profound thrombocytopenia appears to occur in <1% of patients receiving their first course of therapy. Thrombocytopenia can be either acute (<24 hours) or delayed (up to ~14 days). Both hemorrhagic and thrombotic complications have been reported in association with thrombocytopenia. Diagnosis requires exclusion of pseudothrombocytopenia and heparin-induced thrombocytopenia. Therapy based on the severity of thrombocytopenia and symptoms may include drug withdrawals and treatment with steroids, intravenous IgG, and platelet transfusions. Abciximab-associated thrombocytopenia is most common and due to either preformed antibodies or antibodies induced in response to abciximab (delayed). Readministration of abciximab is associated with increased risk of thrombocytopenia. Evidence also supports an immune basis for thrombocytopenia associated with the 2 small molecule GPIs. The latter bind αIIbβ3 like the natural ligands and thus induce the receptor to undergo major conformational changes that potentially create neoepitopes. Thrombocytopenia associated with these drugs is also immune-mediated, with antibodies recognizing the αIIbβ3 receptor only in the presence of the drug. It is unclear whether the antibody binding depends on the conformational change and whether the drug contributes directly to the epitope. Zalunfiban, a second-generation subcutaneous small molecule GPI, does not induce the conformational changes; therefore, data from studies of zalunfiban will provide information on the contribution of the conformational changes to the development of GPI-associated thrombocytopenia.
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Affiliation(s)
- Sem A. O. F. Rikken
- Department of CardiologySt. Antonius HospitalNieuwegeinThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Arnoud W. J. van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
- Department of CardiologyMUMC+MaastrichtThe Netherlands
- Department of CardiologyZuyderland Medical CentreHeerlenThe Netherlands
| | - Jurriën M. ten Berg
- Department of CardiologySt. Antonius HospitalNieuwegeinThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
- Department of CardiologyMUMC+MaastrichtThe Netherlands
| | - Dean J. Kereiakes
- The Christ Hospital Heart and Vascular Institute and Lindner Clinical Research CenterCincinnatiOHUSA
| | - Barry S. Coller
- Allen and Frances Adler Laboratory of Blood and Vascular BiologyRockefeller UniversityNew YorkNYUSA
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Sang H, Xie D, Tian Y, Nguyen TN, Saver JL, Nogueira RG, Wu J, Long C, Tian Z, Hu Z, Wang T, Li R, Ke Y, Zhu X, Peng D, Chang M, Li L, Ruan J, Wu D, Zi W, Yang Q, Li F, Qiu Z. Association of Tirofiban With Functional Outcomes After Thrombectomy in Acute Ischemic Stroke Due to Intracranial Atherosclerotic Disease. Neurology 2023; 100:e1996-e2006. [PMID: 36941074 PMCID: PMC10186214 DOI: 10.1212/wnl.0000000000207194] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/01/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVE To investigate the efficacy and safety of IV infusion of tirofiban before endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerotic disease. The secondary objective was to identify potential mediators for the clinical effect of tirofiban. METHODS Post hoc exploratory analysis of the Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, which was a randomized, double-blinded, placebo-controlled trial at 55 centers in China from October 2018 to October 2021. Patients with occlusion of the internal carotid artery or middle cerebral artery due to intracranial atherosclerosis were included. The primary efficacy outcome was the proportion of patients achieving functional independence (defined as modified Rankin scale 0-2) at 90 days. Binary logistic regression and causal mediation analyses were used to estimate the treatment effect of tirofiban and the potential mediators. RESULTS This study included 435 patients, of whom 71.5% were men. The median age was 65 (interquartile range [IQR] 56-72) years, with a median NIH Stroke Scale of 14 (IQR 10-19). Patients in the tirofiban group had higher rates of functional independence at 90 days than patients in the placebo group (adjusted odds ratio 1.68; 95% CI 1.11-2.56, p = 0.02) without an increased risk of mortality or symptomatic intracranial hemorrhage. Tirofiban was associated with fewer thrombectomy passes (median [IQR] 1 [1-2] vs 1 [1-2], p = 0.004), which was an independent predictor of functional independence. Mediation analysis showed tirofiban-reduced thrombectomy passes explained 20.0% (95% CI 4.1%-76.0%) of the effect of tirofiban on functional independence. DISCUSSION In this post hoc analysis of the RESCUE BT trial, tirofiban was an effective and well-tolerated adjuvant medication of endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerosis. These findings need to be confirmed in future trials. TRIAL REGISTRATION INFORMATION The RESCUE BT trial was registered on the Chinese Clinical Trial Registry: chictr.org.cn, ChiCTR-INR-17014167. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tirofiban plus endovascular therapy improves 90-day outcome for patients with large vessel occlusion due to intracranial atherosclerosis.
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Affiliation(s)
- Hongfei Sang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Dongjing Xie
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Yan Tian
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Thanh N Nguyen
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Jeffrey L Saver
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Raul G Nogueira
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Junxiong Wu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Chen Long
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhenxuan Tian
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhizhou Hu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Tao Wang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Rongzong Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Yingbing Ke
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Xiurong Zhu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Daizhou Peng
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Mingze Chang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Lingfei Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Jie Ruan
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Deping Wu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Wenjie Zi
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Qingwu Yang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Fengli Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhongming Qiu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China.
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Kulick N, Friede KA, Stouffer GA. Safety and efficacy of intracoronary thrombolytic agents during primary percutaneous coronary intervention for STEMI. Expert Rev Cardiovasc Ther 2023; 21:165-175. [PMID: 36825458 DOI: 10.1080/14779072.2023.2184353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Large thrombus burden in patients with ST elevation myocardial infarction (STEMI) is associated with higher rates of distal embolization, no-reflow phenomenon, abrupt closure, stent thrombosis, major adverse cardiovascular events (MACE), and mortality. Intracoronary (IC) thrombolytic agents are theoretically attractive as an adjunct to primary percutaneous coronary intervention (PPCI) as they activate endogenous fibrinolysis which results in degradation of the cross-linked fibrin matrix in coronary thrombus. AREAS COVERED We reviewed published studies reporting on intraprocedural anti-thrombus strategies used during PPCI including randomized controlled trials and observational studies. EXPERT OPINION Published studies are limited by small sample size and heterogeneity due to variation in indication, inclusion criteria, thrombolytic agent, dose, delivery mechanisms, antiplatelet and anticoagulant regimen, timing in regard to reperfusion, PCI techniques, and endpoints. Despite these limitations, data are consistent that IC administration of thrombolytic agents at low doses is associated with low rates of bleeding and vascular complications. While there is currently no compelling data demonstrating a benefit to the routine use of IC thrombolytic therapy in patients with STEMI, there is suggestive data that IC thrombolysis may have benefit in selected patients.
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Affiliation(s)
- Natasha Kulick
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Kevin A Friede
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
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Farag M, Peverelli M, Spinthakis N, Gue YX, Egred M, Gorog DA. Spontaneous Reperfusion in Patients with Transient ST-Elevation Myocardial Infarction-Prevalence, Importance and Approaches to Management. Cardiovasc Drugs Ther 2023; 37:169-180. [PMID: 34245445 DOI: 10.1007/s10557-021-07226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 01/19/2023]
Abstract
Patients with transient ST-elevation myocardial infarction (STEMI) or spontaneous resolution (SpR) of the ST-segment elevation on electrocardiogram could potentially represent a unique group of patients posing a therapeutic management dilemma. In this review, we discuss the potential mechanisms underlying SpR, its relation to clinical outcomes and the proposed management options for patients with transient STEMI with a focus on immediate versus early percutaneous coronary intervention. We performed a structured literature search of PubMed and Cochrane Library databases from inception to December 2020. Studies focused on SpR in patients with acute coronary syndrome were selected. Available data suggest that deferral of angiography and revascularization within 24-48 h in these patients is reasonable and associated with similar or perhaps better outcomes than immediate angiography. Further randomized trials are needed to elucidate the best pharmacological and invasive strategies for this cohort.
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Affiliation(s)
- Mohamed Farag
- Cardiothoracic Department, Freeman Hospital, Newcastle Upon Tyne, UK.
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK.
| | - Marta Peverelli
- Department of Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Nikolaos Spinthakis
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Ying X Gue
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Mohaned Egred
- Cardiothoracic Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Diana A Gorog
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
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Collet JP, Zeitouni M. Heparin pretreatment in STEMI: is earlier always better? EUROINTERVENTION 2022; 18:697-699. [PMID: 36269208 PMCID: PMC10241292 DOI: 10.4244/eij-e-22-00035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Affiliation(s)
- Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Michel Zeitouni
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
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Kumar K, Golwala H. Antiplatelet Agents in Acute ST Elevation Myocardial Infarction. Am J Med 2022; 135:697-708. [PMID: 35202571 DOI: 10.1016/j.amjmed.2022.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/28/2022]
Abstract
Platelet aggregation and thrombus formation represent the basic mechanism for clinical, electrocardiographic, and biomarker changes consistent with acute coronary syndrome. Various oral and intravenous formulations of platelet function inhibitors have been developed to help decrease platelet aggregation due to acute atherosclerotic plaque rupture. In this article, we review the various mechanisms, pharmacokinetics/pharmacodynamics, and the key clinical trials related to the platelet inhibitors that form the basis for current recommendations of their use in the ST elevation myocardial infarction guidelines by the American College of Cardiology/American Heart Association.
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Affiliation(s)
- Kris Kumar
- Oregon Health and Science University, Portland, Ore
| | - Harsh Golwala
- Oregon Health and Science University, Portland, Ore.
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Acute coronary syndromes in diabetic patients, outcome, revascularization, and antithrombotic therapy. Biomed Pharmacother 2022; 148:112772. [PMID: 35245735 DOI: 10.1016/j.biopha.2022.112772] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 01/08/2023] Open
Abstract
Diabetes exacerbates the progression of atherosclerosis and is associated with increased risk of developing acute coronary syndrome (ACS). Approximatively 25-30% of patients admitted for ACS have diabetes. ACS occurs earlier in diabetics and is associated with increased mortality and a higher risk of recurrent ischemic events. An increased proinflammatory and prothrombotic state is involved in the poorer outcomes of diabetic patients. In the past decade advancement in both percutaneous coronary intervention (PCI) and coronary artery by-pass graft (CABG) techniques and more potent antiplatelet drugs like prasugrel and ticagrelor improved outcomes of diabetic patients with ACS, but this population still experiences worse outcomes compared to non-diabetic patients. While in ST elevation myocardial infarction urgent PCI is the method of choice for revascularization, in patients with non-ST elevation ACS an early invasive approach is suggested by the guidelines, but in the setting of multivessel (MV) or complex coronary artery disease (CAD) the revascularization strategy is less clear. This review describes the accumulating evidence regarding factors involved in promoting increased incidence and poor prognosis of ACS in patients with diabetes, the evolution over time of prognosis and outcomes, revascularization strategies and antithrombotic therapy studied until now.
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Ma G, Sun X, Cheng H, Burgin WS, Luo W, Jia W, Liu Y, He W, Geng X, Zhu L, Chen X, Shi H, Xu H, Zhang L, Wang A, Mo D, Ma N, Gao F, Song L, Huo X, Deng Y, Liu L, Luo G, Jia B, Tong X, Liu L, Ren Z, Miao Z. Combined Approach to Eptifibatide and Thrombectomy in Acute Ischemic Stroke Because of Large Vessel Occlusion: A Matched-Control Analysis. Stroke 2022; 53:1580-1588. [PMID: 35105182 DOI: 10.1161/strokeaha.121.036754] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients undergoing mechanical thrombectomy (MT), adjunctive antithrombotic might improve angiographic reperfusion, reduce the risk of distal emboli and reocclusion but possibly expose patients to a higher intracranial hemorrhage risk. This study evaluated the safety and efficacy of combined MT plus eptifibatide for acute ischemic stroke. METHODS This was a propensity-matched analysis of data from 2 prospective trials in Chinese populations: the ANGEL-ACT trial (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) in 111 hospitals between November 2017 and March 2019, and the EPOCH trial (Eptifibatide in Endovascular Treatment of Acute Ischemic Stroke) in 15 hospitals between April 2019 and March 2020. The primary efficacy outcome was good outcome (modified Rankin Scale score 0-2) at 3 months. Secondary efficacy outcomes included the distribution of 3-month modified Rankin Scale scores and poor outcome (modified Rankin Scale score 5-6) and successful recanalization. The safety outcomes included any intracranial hemorrhage, symptomatic intracranial hemorrhage, and 3-month mortality. Mixed-effects logistic regression models were used to account for within-hospital clustering in adjusted analyses. RESULTS Eighty-one combination arm EPOCH subjects were matched with 81 ANGEL-ACT noneptifibatide patients. Compared with the no eptifibatide group, the eptifibatide group had significantly higher rates of successful recanalization (91.3% versus 81.5%; P=0.043) and 3-month good outcomes (53.1% versus 33.3%; P=0.016). No significant difference was found in the remaining outcome measures between the 2 groups. All outcome measures of propensity score matching were consistent with mixed-effects logistic regression models in the total population. CONCLUSIONS This matched-control study demonstrated that MT combined with eptifibatide did not raise major safety concerns and showed a trend of better efficacy outcomes compared with MT alone. Overall, eptifibatide shows potential as a periprocedural adjunctive antithrombotic therapy when combined with MT. Further randomized controlled trials of MT plus eptifibatide should be prioritized. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03844594 (EPOCH), NCT03370939 (ANGEL-ACT).
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Affiliation(s)
- Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Huiran Cheng
- Department of Neurosurgery, Anyang People's Hospital, China (H.C., L.Z.)
| | - W Scott Burgin
- Department of Neurology, Morsani College of Medicine University of South Florida, Tampa (W.S.B.)
| | - Weiliang Luo
- Department of Neurology, Huizhou Municipal Central Hospital, China (W.L.)
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Teaching Hospital, Capital Medical University, China (W.J.)
| | - Yajie Liu
- Department of Neurology, Shenzhen Hospital, Southern Medical University, China (Y.L.)
| | - Wenlong He
- Department of Neurology, Xinxiang Central Hospital, China (W.H.)
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, China (X.G.)
| | - Liangfu Zhu
- Department of Neurosurgery, Anyang People's Hospital, China (H.C., L.Z.).,Department of Cerebral Vascular Diseases, Interventional Center, Henan Provincial People's Hospital, Zhengzhou, China (L.Z.)
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital Xiamen University, China (X.C.)
| | - Huaizhang Shi
- Department of Neurosurgery, the First Affiliated Hospital of Harbin Medical University, China (H.S.)
| | - Haowen Xu
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, China (H.X,)
| | | | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University (A.W.)
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.).,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (L.L.)
| | - Gang Luo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | | | | | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa (Z.R.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
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10
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Tavenier AH, Claassens DMF, Hermanides RS, Vos GJA, Bergmeijer TO, Kelder JC, Deneer VHM, van 't Hof AWJ, Ten Berg JM. Efficacy and safety of glycoprotein IIb/IIIa inhibitors in addition to P2Y 12 inhibitors in ST-segment elevation myocardial infarction: A subanalysis of the POPular Genetics trial. Catheter Cardiovasc Interv 2021; 99:676-685. [PMID: 34233065 DOI: 10.1002/ccd.29861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 06/06/2021] [Accepted: 06/18/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Glycoprotein IIb/IIIa inhibitors (GPI) are still used in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI), although discussion about its clinical benefit is ongoing. METHODS GPI use was analyzed in this subanalysis of the POPular Genetics trial, which randomized STEMI patients to CYP2C19 genotype-guided treatment (clopidogrel or ticagrelor) or standard treatment with ticagrelor/prasugrel. The composite thrombotic endpoint consisted of cardiovascular death, myocardial infarction (MI), definite stent thrombosis, and stroke at 30 days. The combined bleeding endpoint consisted of Platelet Inhibition and Patient Outcomes (PLATO) major and minor bleeding at 30 days. Univariable and multivariable analyses in addition to a propensity score-matched (PSM) analysis were conducted. RESULTS In total, 2378 patients, of whom 1033 received GPI and 1345 did not, were included. In multivariable analysis, GPI administration was associated with fewer thrombotic events (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.09-0.55) and MIs (HR 0.24, 95% CI 0.08-0.73). Furthermore, GPI administration was associated with an increase in bleedings (HR 2.02, 95% CI 1.27-3.19), driven by minor bleedings (HR 2.32, 95% CI 1.43-3.76), without a significant difference in major bleedings (HR 0.69, 95% CI 0.19-2.57). In the PSM analysis, no significant association was found. CONCLUSION In STEMI patients undergoing primary PCI, GPI administration was associated with a reduction in thrombotic events at a cost of an increase in (mostly minor) bleedings in multivariable analysis, while propensity score analysis did not show significant associations.
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Affiliation(s)
- Anne H Tavenier
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - Daniel M F Claassens
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Gerrit J A Vos
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Thomas O Bergmeijer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes C Kelder
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Vera H M Deneer
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arnoud W J van 't Hof
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
- Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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11
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Zhang Y, Hui J, Chen X. Preprocedural Ticagrelor Treatment was Associated with Improved Early Reperfusion and Reduced Short-term Heart Failure in East-Asian ST-segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention. Int J Gen Med 2021; 14:1927-1938. [PMID: 34040425 PMCID: PMC8140910 DOI: 10.2147/ijgm.s307404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose The purpose of this monocentric retrospective observational study is to investigate whether a loading dose of ticagrelor treatment before percutaneous coronary intervention (PCI) procedure improves the early reperfusion and short-term heart function in East-Asian ST segment elevation myocardial infarction (STEMI) patients. Patients and Methods The study included 326 STEMI patients undergoing primary PCI in Jiading Central Hospital. One hundred and forty patients received a loading dose of ticagrelor before entering the catheter laboratory. One hundred and eighty-six patients received a loading dose of ticagrelor in the catheter laboratory before the initiation of PCI. Reperfusion endpoints included the presence of self-patency in the culprit artery, the ST-segment elevation resolution over 50% within 24 h after PCI, and the presence of no-reflow in the culprit artery. Clinical endpoints included all-cause mortality, new-onset heart failure, reinfarction and stent thrombosis within 28 days after PCI. Secondary clinical endpoints included mechanical complications and bleeding events. Results In comparison with the in-lab treatment group, the preprocedural treatment group had a significant higher proportion of self-patency in the culprit artery (25.71% vs 16.67%, P=0.045) and early ST-segment elevation resolution (48.57% vs 27.96%, P<0.001). Preprocedural ticagrelor treatment was associated with a significant reduction of new-onset heart failure (9.29% vs 18.82%, p=0.016). Stent thrombosis risks were numerically reduced in the preprocedural treatment group (0.71% vs 1.61%, P=0.466). The rates of major cardiovascular adverse events, reinfarctions and mortality did not differ between the two groups. Bleeding events in the preprocedural treatment group was notn significantly higher than the in-lab treatment group (4.39% vs 1.39%, P=0.142). Conclusion Preprocedural administration of a loading dose of ticagrelor was associated with improved early reperfusion and reduced short-term heart failure in East-Asian STEMI patients undergoing primary PCI, but care should be taken for excess bleeding events.
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Affiliation(s)
- Yunke Zhang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China.,Department of Cardiology, Shanghai University of Medicine and Health Sciences Affiliated Jiading Central Hospital, Shanghai, 201800, People's Republic of China
| | - Jie Hui
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Xia Chen
- Department of Cardiology, Shanghai University of Medicine and Health Sciences Affiliated Jiading Central Hospital, Shanghai, 201800, People's Republic of China
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12
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Capranzano P, Angiolillo DJ. Tackling the gap in platelet inhibition with oral antiplatelet agents in high-risk patients undergoing percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2021; 19:519-535. [PMID: 33881367 DOI: 10.1080/14779072.2021.1920925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Oral P2Y12 inhibitors represent the mainstay therapy for the prevention of thrombotic complications in patients presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI). However, the onset of antiplatelet action of the oral P2Y12 inhibitors is affected by their need to be absorbed in the gastrointestinal (GI) tract before becoming systemically available.Areas covered: Following oral intake of P2Y12 inhibitors, the timeframe required for GI absorption leads to a window of inadequate antiplatelet protection during which patients are at increased thrombotic risk. The onset of action of the oral P2Y12 inhibitors is even further delayed in high-risk patients, underscoring the need to define strategies to bridge the gap in platelet inhibitory effects following their intake.Expert opinion: Multiple mechanisms may impair GI absorption leading to a delay in the onset of action of oral P2Y12 inhibitors. Several strategies have been tested to overcome the gap in platelet inhibition in high-risk patients undergoing PCI. These include administration of crushed or chewed tablets to improve the dissolution rate and use of opioid receptor antagonists or metoclopramide to counteract impairment of gastric motility induced by opioids. However, intravenous antiplatelet therapies represent the most effective strategy to bridge such gap in platelet inhibition.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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13
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Vlachojannis GJ, Wilschut JM, Vogel RF, Lemmert ME, Delewi R, Diletti R, van der Waarden NW, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Van Mieghem NM, Smits PC. Effect of Prehospital Crushed Prasugrel Tablets in Patients With ST-Segment–Elevation Myocardial Infarction Planned for Primary Percutaneous Coronary Intervention. Circulation 2020; 142:2316-2328. [DOI: 10.1161/circulationaha.120.051532] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background:
Early treatment with a potent oral platelet P2Y
12
inhibitor is recommended in patients presenting with ST-segment–elevation myocardial infarction scheduled to undergo primary percutaneous coronary intervention (pPCI). The impact on coronary reperfusion of crushed P2Y
12
inhibitor tablets, which lead to more prompt and potent platelet inhibition, is unknown.
Methods:
We conducted a randomized controlled, multicenter trial in the Netherlands, enrolling patients with ST-segment–elevation myocardial infarction scheduled to undergo pPCI. Patients were randomly allocated to receive in the ambulance, before transfer, a 60-mg loading dose of prasugrel either as crushed or integral tablets. The independent primary end points were thrombolysis in myocardial infarction (TIMI) 3 flow in the infarct-related artery at initial coronary angiography, and complete (≥70%) ST-segment resolution 1 hour after pPCI. The safety end points were TIMI major and Bleeding Academic Research Consortium ≥3 bleedings. Secondary end points included platelet reactivity and ischemic outcomes.
Results:
A total of 727 patients were assigned to either crushed or integral tablets of prasugrel loading dose. The median time from study treatment to wire-crossing during pPCI was 57 (47–70) minutes. The primary end point TIMI 3 flow in the infarct-related artery before pPCI occurred in 31.0% in the crushed group versus 32.7% in the integral group (odds ratio, 0.92 [95% CI, 0.65–1.30],
P
=0.64). Complete ST-segment resolution 1 hour after pPCI was present in 59.9% in the crushed group versus 57.3% in the integral group (odds ratio, 1.11 [95% CI, 0.78–1.58],
P
=0.55). Platelet reactivity at the beginning of pPCI, measured as P2Y
12
reactivity unit, differed significantly between groups (crushed, 192 [132–245] versus integral, 227 [184–254],
P
≤0.01). TIMI major and Bleeding Academic Research Consortium ≥3 bleeding occurred in 0% in the crushed group versus 0.8% in the integral group, and in 0.3% in the crushed group versus 1.1% in the integral group, respectively. There were no differences observed between groups regarding ischemic events at 30 days.
Conclusions:
Prehospital administration of crushed prasugrel tablets does not improve TIMI 3 flow in the infarct-related artery before pPCI or complete ST-segment resolution 1 h after pPCI in patients presenting with ST-segment–elevation myocardial infarction scheduled for pPCI.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT03296540.
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Affiliation(s)
- Georgios J. Vlachojannis
- University Medical Center Utrecht, The Netherlands (G.J.V., R.F.V.)
- Maasstad Hospital, Rotterdam, The Netherlands (G.J.V., V.P., P.C.S.)
| | - Jeroen M. Wilschut
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Rosanne F. Vogel
- University Medical Center Utrecht, The Netherlands (G.J.V., R.F.V.)
| | - Miguel E. Lemmert
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
- Isala Hospital, Zwolle, The Netherlands (M.E.L.)
| | - Ronak Delewi
- Amsterdam University Medical Center, The Netherlands (R. Delewi). Ambulance Zorg Rotterdam-Rijnmond, Barendrecht, The Netherlands (N.W.P.L.v.d.W.)
| | - Roberto Diletti
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Nancy W.P.L. van der Waarden
- Amsterdam University Medical Center, The Netherlands (R. Delewi). Ambulance Zorg Rotterdam-Rijnmond, Barendrecht, The Netherlands (N.W.P.L.v.d.W.)
| | - Rutger-Jan Nuis
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Valeria Paradies
- Maasstad Hospital, Rotterdam, The Netherlands (G.J.V., V.P., P.C.S.)
| | - Dimitrios Alexopoulos
- National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Greece (D.A.)
| | - Felix Zijlstra
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Gilles Montalescot
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
- Sorbonne University, ACTION group, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Paris, France (G.M.)
| | | | | | - Nicolas M. Van Mieghem
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Pieter C. Smits
- Maasstad Hospital, Rotterdam, The Netherlands (G.J.V., V.P., P.C.S.)
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14
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Yang J, Wu Y, Gao X, Bivard A, Levi CR, Parsons MW, Lin L. Intraarterial Versus Intravenous Tirofiban as an Adjunct to Endovascular Thrombectomy for Acute Ischemic Stroke. Stroke 2020; 51:2925-2933. [PMID: 32933416 DOI: 10.1161/strokeaha.120.029994] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE This study aimed to evaluate the treatment effect of intraarterial versus intravenous tirofiban during endovascular thrombectomy in acute ischemic stroke. METHODS This study retrospectively examined 503 patients with acute ischemic stroke with large vessel occlusion who received endovascular thrombectomy within 24 hours of stroke onset. Patients were divided into 3 groups: no tirofiban (n=354), intraarterial tirofiban (n=79), and intravenous tirofiban (n=70). The 3 groups were compared in terms of recanalization rate, symptomatic intracerebral hemorrhage, in-hospital death rate, 3-month death, and 3-month outcomes measured by modified Rankin Scale score (good clinical outcome of 0-2, poor outcome of 5-6). The comparison was statistically assessed by propensity score matching, followed by Freidman rank-sum test and pairwise Wilcoxon signed-rank test with Bonferroni correction. RESULTS The propensity score matching resulted in 92 matched triplets. Compared with the no-tirofiban group, the intravenous tirofiban group showed significantly increased recanalization (96.7% versus 64.1%, P<0.001), an increased rate of 3-month good outcome (69.5% versus 51.2%, P=0.034), and a lower rate of 3-month poor outcome (12.2% versus 41.4%, P<0.001). There was no significant difference between the tirofiban intravenous and no-tirofiban groups in terms of symptomatic intracerebral hemorrhage (2.2% versus 0%, P=1.000). However, symptomatic intracerebral hemorrhage was significantly increased in the intraarterial-tirofiban group compared with the no-tirofiban group (19.1% versus 0%, P<0.001), with an increased rate of in-hospital death (23.6% versus 0% P<0.001), and increased rate of 3-month death (26.8% versus 11.1%, P=0.021). The intraarterial-tirofiban and no-tirofiban group showed no significant difference in recanalization rate (66.3% versus 64.1%, P=1.000). CONCLUSIONS As an adjunct to endovascular thrombectomy, intravenous tirofiban is associated with high recanalization rate and good outcome, whereas intraarterial tirofiban is associated with high hemorrhagic rate and death rate.
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Affiliation(s)
- Jianhong Yang
- Department of Neurology (J.Y., Y.W.), Ningbo First Hospital, Zhejiang, China
| | - Yuefei Wu
- Department of Neurology (J.Y., Y.W.), Ningbo First Hospital, Zhejiang, China
| | - Xiang Gao
- Department of Neurosurgery (X.G.), Ningbo First Hospital, Zhejiang, China
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (A.B., M.W.P.)
| | - Christopher R Levi
- School of Medicine and Public Health, University of Newcastle, Australia (C.R.L., M.W.P., L.L.)
| | - Mark W Parsons
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (A.B., M.W.P.).,School of Medicine and Public Health, University of Newcastle, Australia (C.R.L., M.W.P., L.L.)
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Australia (C.R.L., M.W.P., L.L.)
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15
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Shavadia JS, Granger CB, Alemayehu W, Westerhout CM, Povsic TJ, Brener SJ, van Diepen S, Defilippi C, Armstrong PW. High-throughput targeted proteomics discovery approach and spontaneous reperfusion in ST-segment elevation myocardial infarction. Am Heart J 2020; 220:137-144. [PMID: 31812755 DOI: 10.1016/j.ahj.2019.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although spontaneous reperfusion (SR) prior to primary percutaneous coronary intervention (pPCI) is associated with improved outcomes, its pathophysiology remains unclear. The objective of the study was to explore associations between SR in ST-segment elevation myocardial infarction (STEMI) using a multimarker cardiovascular proteins strategy METHODS: We evaluated STEMI patients from the Assessment of Pexelizumab in Acute Myocardial Infarction trial treated with pPCI within 6 hours from symptom onset. SR was core laboratory-defined as pre-PCI Thrombolysis in Myocardial Infarction flow 2 or 3. Ninety-one cardiovascular disease-related serum biomarkers drawn prior to PCI were analyzed using a high-throughput "targeted discovery" panel. Expression levels for individual biomarkers were compared between patients with/without SR. A hierarchical clustering method of biomarkers identified clusters of biomarkers that differentiated the 2 groups. Associations between individual biomarkers and clusters with SR were further evaluated by multivariable logistic regression. RESULTS Of 683 patients studied, 290 had spontaneous reperfusion; those with compared to without SR were more likely noninferior STEMI and had lower clinical acuity and lower baseline levels of troponin and creatine kinase. SR was associated with a lower occurrence of 90-day composite of death, heart failure, or cardiogenic shock. Fifty-two of 91 individual biomarkers were significantly univariably associated with SR. Forty-five remained significant with adjustment for false discovery rate. Using cluster analysis, 26 biomarkers clusters were identified, explaining 72% of total covariance, and 13 biomarker clusters were significantly associated with SR after multivariable adjustment. SR was associated with higher mean expression levels of proteins in all 13 clusters. The cluster most strongly associated with SR consisted of novel proteins across various distinct, yet interlinked, pathobiological processes (kallikrein-6, matrix extracellular phosphoglycoprotein, matrix mettaloproteinaise-3, and elafin). CONCLUSIONS Spontaneous reperfusion prior to pPCI in STEMI was associated with a lower risk of adverse clinical events. These exploratory data from a targeted discovery proteomics platform identifies novel proteins across diverse, yet complementary, pathobiological axes that show promise in providing mechanistic insights into spontaneous reperfusion in STEMI. CONDENSED ABSTRACT Spontaneous reperfusion has been established with improved STEMI outcomes, yet its pathobiology is unclear and appears to involve diverse physiological processes. Using a 91-biomarker high-throughput proteomics platform, we studied 683 STEMI patients in the APEX AMI trial (290 had core laboratory-adjudicated pre-PCI TIMI 2/3 flow) and identified 52 proteins that univariably associate with spontaneous reperfusion. Cluster analysis identified 26 biomarker clusters (explaining 72% of total variance), 13 of which, after multivariable adjustment, were significantly associated with spontaneous reperfusion. Four proteins (kallikrein-6, matrix extracellular phosphoglycoprotein, matrix mettaloproteinaise-3, and elafin) across diverse, yet complementary, pathways appear to be associated most strongly with spontaneous reperfusion.
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Affiliation(s)
- Jay S Shavadia
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Duke Clinical Research Institute, Durham, NC, USA.
| | | | | | | | | | - Sorin J Brener
- Department of Medicine, Cardiac Catheterization Laboratory, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Sean van Diepen
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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16
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Antithrombotics: From Aspirin to DOACs in Coronary Artery Disease and Atrial Fibrillation (Part 3/5). J Am Coll Cardiol 2019; 74:699-711. [PMID: 31277840 DOI: 10.1016/j.jacc.2019.02.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/22/2019] [Accepted: 02/04/2019] [Indexed: 01/09/2023]
Abstract
For secondary prevention of coronary artery disease (CAD), oral antiplatelet therapy is essential. In case of coronary intervention, temporary dual antiplatelet therapy is mandatory as well. Recently, low-dose oral anticoagulation has entered the CAD arena. Atrial fibrillation (AF) is often seen in CAD and vice versa. In most patients stroke prevention in AF consists of oral anticoagulation. In many cases of CAD in patients with AF, anticoagulation has to be combined with antiplatelet agents (so called, dual pathway antithrombotic therapy). Excess bleeding in these conditions is a rapidly rising problem. This review addresses the antithrombotic options in CAD alone, in AF alone, and in their combination, when either an invasive or a noninvasive approach has been chosen.
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17
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Characteristics and outcomes of patients requiring bailout use of glycoprotein IIb/IIIa inhibitors for thrombotic complications of percutaneous coronary intervention: An analysis from the CHAMPION PHOENIX trial. Int J Cardiol 2018; 278:217-222. [PMID: 30563770 DOI: 10.1016/j.ijcard.2018.11.114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 10/08/2018] [Accepted: 11/22/2018] [Indexed: 11/21/2022]
Abstract
AIMS To describe the characteristics and outcomes of patients receiving bailout glycoprotein IIb/IIIa inhibitors (GPI) for thrombotic complications of percutaneous coronary intervention (PCI) in a large, contemporary trial. METHODS AND RESULTS In the CHAMPION PHOENIX trial, the use of GPI was restricted to bailout for thrombotic complications. We describe the characteristics and outcomes of patients requiring bailout GPI compared to patients not receiving GPIs, with adjustment through propensity-score. A multivariable model was constructed to identify independent correlates associated with bailout GPI use. A total of 380 out of 10,942 patients received GPI (3.5%); GPI patients were younger, more frequently male, more likely to present with ST segment elevation myocardial infarction and less frequently treated with cangrelor. At 48 h, GPI patients experienced higher rates of the primary composite outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis (ST) (19.2% vs 4.8%; adjusted OR: 5.65(4.08, 7.82), p < 0.0001) and a higher rate of GUSTO severe or moderate bleeding (2.6% vs 0.4% adjusted OR: 4.90 (1.98, 12.18), p = 0.0006) compared with non GPI patients. Independent correlates of GPI use were STEMI, use of unfractionated heparin, drug-eluting stents and longer procedure duration. CONCLUSIONS In a large contemporary trial, patients receiving bailout GPI for thrombotic complications of PCI experienced very high risks of both ischemic and bleeding complications, suggesting that prevention of periprocedural complications rather than bailout GPI may be preferable. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov identifier: NCT01156571.
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Hashimoto T, Ako J, Nakao K, Ozaki Y, Kimura K, Noguchi T, Yasuda S, Suwa S, Fujimoto K, Nakama Y, Morita T, Shimizu W, Saito Y, Hirohata A, Morita Y, Inoue T, Okamura A, Uematsu M, Hirata K, Tanabe K, Shibata Y, Owa M, Tsujita K, Funayama H, Kokubu N, Kozuma K, Uemura S, Toubaru T, Saku K, Oshima S, Nakai M, Nishimura K, Miyamoto Y, Ogawa H, Ishihara M. Pre-Procedural Thrombolysis in Myocardial Infarction Flow in Patients with ST-Segment Elevation Myocardial Infarction. Int Heart J 2018; 59:920-925. [PMID: 30158385 DOI: 10.1536/ihj.17-518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
It has been shown that the patency of an infarct-related artery (IRA) before primary percutaneous coronary intervention determines post-procedural success, better preservation of left ventricular function, and lower in-hospital mortality. However, the factors associated with pre-procedural Thrombolysis In Myocardial Infarction (TIMI) flow have not been fully investigated.The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry conducted at 28 Japanese medical institutions between July 2012 and March 2014. We enrolled 3,283 consecutive patients with acute myocardial infarction who were admitted to a participating institution within 48 hours of symptom onset. There were 2,262 patients (68.9%) with ST-elevation myocardial infarction (STEMI), among whom 2,182 patients underwent emergent or urgent coronary angiography.Pre-procedural TIMI flow grade 3 was related to post-procedural TIMI flow grade 3 (P < 0.001), lower enzymatic infarct size (P < 0.001), lower ventricular tachycardia and ventricular fibrillation (P = 0.049), and lower in-hospital mortality (P = 0.020). A history of antiplatelet drug use was associated with pre-procedural TIMI flow.Antiplatelet drug use on admission was associated with pre-procedural TIMI flow. The patency of the IRA in patients with STEMI was related to procedural success and decreased enzymatic infarct size, fatal arrhythmic events, and in-hospital mortality.
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Affiliation(s)
- Takuya Hashimoto
- Kitasato University Graduate School of Medical Sciences.,Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Junya Ako
- Kitasato University Graduate School of Medical Sciences.,Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University
| | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Kazuteru Fujimoto
- Department of Cardiology, National Hospital Organization Kumamoto Medical Center
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Yoshihiko Saito
- First Department of Internal Medicine, Nara Medical University
| | - Atsushi Hirohata
- Department of Cardiovascular Medicine, The Sakakibara Heart Institute of Okayama
| | | | - Teruo Inoue
- Department of Cardiovascular Medicine, Dokkyo Medical University
| | | | | | | | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Mafumi Owa
- Department of Cardiovascular Medicine, Suwa Red Cross Hospital
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Hiroshi Funayama
- Division of Cardiovascular Medicine, Saitama Medical Center Jichi Medical University
| | - Nobuaki Kokubu
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Ken Kozuma
- Department of Cardiology, Teikyo University
| | | | | | - Keijirou Saku
- Department of Cardiology, Fukuoka University School of Medicine
| | - Shigeru Oshima
- Department of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center
| | - Kunihiro Nishimura
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center
| | - Yoshihiro Miyamoto
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Silvain J, Storey RF, Cayla G, Esteve JB, Dillinger JG, Rousseau H, Tsatsaris A, Baradat C, Salhi N, Hamm CW, Lapostolle F, Lassen JF, Collet JP, ten Berg JM, van ’t Hof AW, Montalescot G. P2Y12 receptor inhibition and effect of morphine in patients undergoing primary PCI for ST-segment elevation myocardial infarction. Thromb Haemost 2018; 116:369-78. [DOI: 10.1160/th15-12-0944] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/19/2016] [Indexed: 01/08/2023]
Abstract
SummaryPRIVATE-ATLANTIC (P2Y12 Receptor Inhibition with VASP Testing using Elisa kit during the ATLANTIC study) is a pre-specified substudy of the randomised, double-blind ATLANTIC trial in patients with ST-segment elevation myocardial infarction, designed to help interpret the main trial results. The primary objective of ATLANTIC was to assess coronary reperfusion prior to percutaneous coronary intervention (PCI) with pre- vs in-hospital ticagrelor 180 mg loading dose (LD). PRIVATE-ATLANTIC assessed platelet inhibition in 37 patients by measurement of vasodilator-associated stimulated phosphoprotein (VASP) platelet reactivity index (PRI) and VerifyNow platelet reactivity units (PRU) before angiogram (T1), immediately after PCI (T2), 1 (T3), and 6 (T4) hours (h) after PCI, and before next study drug administration (T5). The median time difference between the two ticagrelor LD was 41 minutes. Platelet reactivity was unaffected at T1 when measured by VASP-PRI (89.8 vs 93.9% for pre- and in-hospital ticagrelor, respectively; p = 0.18) or PRU (239 vs 241; p = 0.82). Numerical differences were apparent at T2 and maximal at T3. Morphine administration significantly delayed onset of platelet inhibition at T3 (VASP-PRI 78.2 vs 23.4% without morphine; p = 0.0116) and T4 (33.1 vs 11.0%; p = 0.0057). In conclusion, platelet inhibition in ATLANTIC was unaffected by pre-hospital ticagrelor administration at the time of initial angiogram due to the short transfer delay. The maximum difference in platelet inhibition was detected 1 h after PCI (T3). Morphine administration was associated with delayed onset of action of ticagrelor and appeared more important than timing of ticagrelor administration.
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Cayla G, Lapostolle F, Ecollan P, Stibbe O, Benezet JF, Henry P, Hammett CJ, Lassen JF, Storey RF, Ten Berg JM, Hamm CW, Van't Hof AW, Montalescot G. Pre-hospital ticagrelor in ST-segment elevation myocardial infarction in the French ATLANTIC population. Int J Cardiol 2017. [PMID: 28622941 DOI: 10.1016/j.ijcard.2017.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND ATLANTIC was a randomized study comparing pre- and in-hospital treatment with a ticagrelor loading dose (LD) in ongoing ST-segment elevation myocardial infarction (STEMI). We sought to compare patient characteristics and clinical outcomes in France with other countries participating in ATLANTIC. METHODS The population comprised 1862 patients, 660 (35.4%) from France and 1202 from 12 other countries. The main endpoints were reperfusion (≥70% ST-segment elevation resolution) and TIMI flow grade 3 before (co-primary endpoints) and after percutaneous coronary intervention (PCI). Other endpoints included a composite ischaemic endpoint (death/myocardial infarction/stroke/urgent revascularization/definite stent thrombosis) and bleeding events at 30days. RESULTS In France, median times from first LD to angiography and between first and second LDs were 49 and 35min, respectively, and were similar to other countries. French patients were younger (mean 58.7 vs 61.9years, p<0.0001) and characterized by a higher rate of radial access (89.9% vs 54.8%, p<0.0001), more frequent use of pre-hospital glycoprotein (GP) IIb/IIIa inhibitors (14.1% vs 3.1%, p<0.0001) and intravenous enoxaparin (57.3% vs 10.1%, p<0.0001). In France, as in other countries, the co-primary endpoints did not differ between the two randomization groups. The composite ischaemic endpoint was numerically lower in France (3.3% vs 5.1%, p=0.07), with a lower mortality (1.4% vs 3.3%, p=0.01). PLATO major bleeding was numerically less frequent in France (1.8% vs 3.2%, p=0.07). CONCLUSIONS The French population appears to have better outcomes than the rest of the study population, and seems related to differences in demographics and management characteristics. TRIAL REGISTRY ClinicalTrials.gov (NCT01347580).
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Affiliation(s)
- Guillaume Cayla
- Department of Cardiology, CHU Caremeau, Université de Montpellier, Nîmes, France.
| | | | | | | | | | | | - Christopher J Hammett
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jens Flensted Lassen
- Department of Cardiology B, Aarhus University Hospital, Skejby, Aarhus N, Denmark
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jur M Ten Berg
- Department of Cardiology, St Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart Center, Bad Neuheim, Germany
| | | | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, Institut de Cardiologie (AP-HP), CHU Pitié-Salpêtrière, INSERM UMRS, 1166 Paris, France
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21
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Verheugt FWA. Antithrombotic Therapy to Reduce Ischemic Events in Acute Coronary Syndromes Patients Undergoing Percutaneous Coronary Intervention. Interv Cardiol Clin 2017; 6:131-140. [PMID: 27886817 DOI: 10.1016/j.iccl.2016.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Antithrombotic therapy is essential in the prevention of periprocedural death and myocardial infarction during and after percutaneous coronary intervention. In the pathogenesis of acute coronary syndromes (ACS), both platelets and the coagulation cascade play an important role. Therefore, periprocedural antithrombotic therapy is even more important in ACS than in elective PCI. The most used agents are aspirin, platelet P2Y12 blockers, platelet glycoprotein IIb/IIIa blockers, and parenteral anticoagulants. The P2Y12 blockers must be continued at least 12 months. High-risk patients should be treated with glycoprotein IIb/IIIa receptor antagonists, especially those undergoing primary angioplasty for ST-elevation acute coronary syndrome.
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Affiliation(s)
- Freek W A Verheugt
- Division of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, Amsterdam 1091 AC, Netherlands.
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22
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Yang Y, Li J, Xu W, Dong S, Yu H, Song H, Chu Y. Thrombus aspirated from patients with ST-elevation myocardial infarction: Clinical and angiographic outcomes. J Int Med Res 2016; 44:1514-1523. [PMID: 27834302 PMCID: PMC5536757 DOI: 10.1177/0300060516667373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To investigate differences in clinical and angiographic outcomes between patients with acute myocardial infarction with red and white thrombi. Methods A total of 137 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary interventions were included. Thrombus material was classified as white or red based on its pathology. Information on characteristics of thrombi was available for 97 (70.8%) patients. Results The total ischaemic time was significantly longer in the red thrombus group compared with the white thrombus group. The incidence of major adverse cardiovascular events in hospital was higher in the red thrombus group than in the white thrombus group (15.6% vs 0%). Multivariable logistic analysis showed that the total ischaemic time was the only predictor of thrombus composition (odds ratio 1.353; 95% confidence interval 1.003, 1.826). Conclusion Red thrombi were present in nearly two-thirds of cases, and were associated with a longer ischaemic time and higher incidence of major adverse cardiovascular events in hospital.
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Affiliation(s)
- Yapan Yang
- 1 Department of Cardiology, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Jingchao Li
- 1 Department of Cardiology, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Wenke Xu
- 2 Department of Emergency Center, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Shujuan Dong
- 1 Department of Cardiology, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Haijia Yu
- 2 Department of Emergency Center, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Huihui Song
- 2 Department of Emergency Center, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Yingjie Chu
- 1 Department of Cardiology, Zhengzhou University People's Hospital, Zhengzhou, China
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24
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Bailleul C, Puymirat E, Aissaoui N, Schiele F, Ducrocq G, Coste P, Blanchard D, Brasselet C, Elbaz M, Steg PG, Le Breton H, Bonnefoy-Cudraz E, Montalescot G, Cottin Y, Goldstein P, Ferrières J, Simon T, Danchin N. Factors Associated With Infarct-Related Artery Patency Before Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction (from the FAST-MI 2010 Registry). Am J Cardiol 2016; 117:17-21. [PMID: 26541905 DOI: 10.1016/j.amjcard.2015.09.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/25/2015] [Accepted: 09/25/2015] [Indexed: 10/22/2022]
Abstract
Early infarct-related artery (IRA) patency is associated with better clinical outcomes in patients with ST-elevation myocardial infarction (STEMI). Using the French Registry of ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2010 registry, we investigated factors related to IRA patency (thrombolysis in myocardial infarction [TIMI] 2/3 flow) at the start of procedure in patients admitted for primary percutaneous coronary intervention. FAST-MI 2010 is a nationwide French registry including 4,169 patients with acute MI. Of 1,452 patients with STEMI with primary percutaneous coronary intervention, 466 (32%) had TIMI 2/3 flow of IRA before the procedure. Mean age (62 ± 14 years in both groups), Global Registry of Acute Coronary Event score (141 ± 31 vs 142 ± 34), and time from onset to angiography (472 ± 499 vs 451 ± 479 minutes) did not differ according to IRA patency (TIMI 2/3 vs TIMI 0/1). Using multivariate logistic regression analysis, IRA patency was more frequently found in patients having called earlier (time from onset to electrocardiogram [ECG] <120 minutes; odds ratio [OR] 1.49; 95% confidence interval [CI] 1.17 to 1.89), or receiving rapid-onset of action (prasugrel or glycoprotein IIb-IIIa) antiplatelet therapy in the prehospital setting (OR 1.59, 95% CI 1.14 to 2.21). Increasing time from diagnostic ECG to angiography was also associated with IRA patency (>90 minutes; OR 1.37, 95% CI 1.08 to 1.75). In conclusion, preprocedural IRA patency is observed in one third of patients with STEMI, it is more frequently found in patients having received fast-acting antiplatelet therapy before angiography, and in patients having called early. Higher IRA patency with increasing time delays from qualifying ECG to angiography suggests an additional role of spontaneous or medication-mediated fibrinolysis.
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25
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Zhao XM, Gao CY, Chu YJ, Yang L, Yang XZ, Xu WK, He WQ, Zhang PR, Liu XY, Tian LX. Fondaparinux vs. enoxaparin in patients with non-ST elevation acute coronary syndromes (NSTE-ACS) treated with percutaneous coronary intervention and tirofiban: an exploratory study in China. J Clin Pharm Ther 2015; 40:584-589. [PMID: 26249542 DOI: 10.1111/jcpt.12315] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/02/2015] [Indexed: 11/28/2022]
Affiliation(s)
- X. M. Zhao
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - C. Y. Gao
- Department of Cardiology; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - Y. J. Chu
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - L. Yang
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - X. Z. Yang
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - W. K. Xu
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - W. Q. He
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - P. R. Zhang
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - X. Y. Liu
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - L. X. Tian
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
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De Backer O, Ratcovich H, Biasco L, Pedersen F, Helqvist S, Saunamäki K, Tilsted HH, Clemmensen P, Olivecrona G, Kelbaek H, Jørgensen E, Engstrøm T, Holmvang L. Prehospital administration of P2Y12 inhibitors and early coronary reperfusion in primary PCI: an observational comparative study. Thromb Haemost 2015; 114:623-31. [PMID: 25994355 DOI: 10.1160/th15-01-0026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 04/03/2015] [Indexed: 01/20/2023]
Abstract
The newer oral P2Y12 inhibitors prasugrel and ticagrelor have been reported to be more potent and faster-acting antiplatelet agents than clopidogrel. This study aimed to investigate whether prehospital loading with prasugrel or ticagrelor improves early coronary reperfusion as compared to prehospital loading with clopidogrel in a real-world ST-elevation myocardial infarction (STEMI) setting. Over a 70-month period, 3497 patients with on-going STEMI of less than 6 hours and without cardiac arrest or cardiogenic shock underwent primary percutaneous coronary intervention (PPCI) at our centre. The primary endpoint of this study was the proportion of patients who did not meet the criteria for TIMI (Thrombolysis In Myocardial Infarction) flow grade 3 in the infarct-related artery at initial angiography before PPCI. Prehospital loading with prasugrel (n = 883) or ticagrelor (n = 491) did not significantly improve coronary reperfusion as compared to prehospital loading with clopidogrel (n = 1,532) - a TIMI-flow 3 at initial angiography was absent in 71.7 %, 69.0 % and 71.5 % of patients, respectively. Major adverse cardiac event (MACE) rates were low at 30 days (3.4 % to 4.0 %) and did not significantly differ between the different P2Y12 inhibitor regimens. In conclusion, this large observational, non-randomised study is the first to show that prehospital loading with the newer P2Y12 inhibitors does not improve early coronary reperfusion as compared to prehospital loading with clopidogrel in a PPCI cohort excluding cardiac arrest and cardiogenic shock.
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Affiliation(s)
- Ole De Backer
- Ole De Backer, MD, PhD, Kardiologisk klinik B 2012, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark, Tel.: +45 35457086, E-mail:
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Montalescot G, van 't Hof AW, Lapostolle F, Silvain J, Lassen JF, Bolognese L, Cantor WJ, Cequier A, Chettibi M, Goodman SG, Hammett CJ, Huber K, Janzon M, Merkely B, Storey RF, Zeymer U, Stibbe O, Ecollan P, Heutz WMJM, Swahn E, Collet JP, Willems FF, Baradat C, Licour M, Tsatsaris A, Vicaut E, Hamm CW. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 2014; 371:1016-27. [PMID: 25175921 DOI: 10.1056/nejmoa1407024] [Citation(s) in RCA: 475] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The direct-acting platelet P2Y12 receptor antagonist ticagrelor can reduce the incidence of major adverse cardiovascular events when administered at hospital admission to patients with ST-segment elevation myocardial infarction (STEMI). Whether prehospital administration of ticagrelor can improve coronary reperfusion and the clinical outcome is unknown. METHODS We conducted an international, multicenter, randomized, double-blind study involving 1862 patients with ongoing STEMI of less than 6 hours' duration, comparing prehospital (in the ambulance) versus in-hospital (in the catheterization laboratory) treatment with ticagrelor. The coprimary end points were the proportion of patients who did not have a 70% or greater resolution of ST-segment elevation before percutaneous coronary intervention (PCI) and the proportion of patients who did not have Thrombolysis in Myocardial Infarction flow grade 3 in the infarct-related artery at initial angiography. Secondary end points included the rates of major adverse cardiovascular events and definite stent thrombosis at 30 days. RESULTS The median time from randomization to angiography was 48 minutes, and the median time difference between the two treatment strategies was 31 minutes. The two coprimary end points did not differ significantly between the prehospital and in-hospital groups. The absence of ST-segment elevation resolution of 70% or greater after PCI (a secondary end point) was reported for 42.5% and 47.5% of the patients, respectively. The rates of major adverse cardiovascular events did not differ significantly between the two study groups. The rates of definite stent thrombosis were lower in the prehospital group than in the in-hospital group (0% vs. 0.8% in the first 24 hours; 0.2% vs. 1.2% at 30 days). Rates of major bleeding events were low and virtually identical in the two groups, regardless of the bleeding definition used. CONCLUSIONS Prehospital administration of ticagrelor in patients with acute STEMI appeared to be safe but did not improve pre-PCI coronary reperfusion. (Funded by AstraZeneca; ATLANTIC ClinicalTrials.gov number, NCT01347580.).
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28
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Estévez-Loureiro R, López-Sainz &A, Pérez de Prado A, Cuellas C, Calviño Santos R, Alonso-Orcajo N, Salgado Fernández J, Vázquez-Rodríguez JM, López-Benito M, Fernández-Vázquez F. Timely reperfusion for ST-segment elevation myocardial infarction: Effect of direct transfer to primary angioplasty on time delays and clinical outcomes. World J Cardiol 2014; 6:424-433. [PMID: 24976914 PMCID: PMC4072832 DOI: 10.4330/wjc.v6.i6.424] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/09/2014] [Indexed: 02/07/2023] Open
Abstract
Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) when it can be performed expeditiously and by experienced operators. In spite of excellent clinical results this technique is associated with longer delays than thrombolysis and this fact may nullify the benefit of selecting this therapeutic option. Several strategies have been proposed to decrease the temporal delays to deliver PPCI. Among them, prehospital diagnosis and direct transfer to the cath lab, by-passing the emergency department of hospitals, has emerged as an attractive way of diminishing delays. The purpose of this review is to address the effect of direct transfer on time delays and clinical events of patients with STEMI treated by PPCI.
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Angiographic outcomes with early eptifibatide therapy in non-ST-segment elevation acute coronary syndrome (from the EARLY ACS Trial). Am J Cardiol 2014; 113:1297-305. [PMID: 24607027 DOI: 10.1016/j.amjcard.2014.01.404] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 01/11/2014] [Accepted: 01/11/2014] [Indexed: 01/23/2023]
Abstract
Early administration of glycoprotein IIbIIIa inhibitors results in improved angiographic parameters, including thrombolysis in myocardial infarction (TIMI) flow grade, corrected TIMI frame count, and TIMI myocardial perfusion grade (TMPG) among patients with ST-segment elevation myocardial infarction. Whether the same is true in the setting of non-ST-segment elevation acute coronary syndrome is unknown. The goal of the early glycoprotein IIbIIIa inhibition in non-ST-segment elevation acute coronary syndrome (EARLY ACS) angiographic substudy was to compare angiographic outcomes among patients with non-ST-segment elevation acute coronary syndrome who were administered early routine versus delayed provisional eptifibatide. Of 9,406 patients in the EARLY ACS trial, 2,066 patients were included in the angiographic substudy (early routine eptifibatide [n=1,042] or early placebo [n=1,024] with delayed provisional eptifibatide after angiography and before percutaneous coronary intervention [PCI]). The angiographic substudy primary end point was the incidence of TMPG 3 before and after PCI. TMPG 3 before (43.7% vs 44.9%, p=0.58) and after PCI (52.4% vs 50.1%, p=0.73) was similar for early routine versus delayed provisional eptifibatide, respectively. Angiographic procedural complications consisting of a composite of loss of side branch, abrupt vessel closure, distal embolization, and no reflow occurred less frequently in early routine group versus delayed provisional group (9.3% vs 13.6%, respectively, p=0.01). In the EARLY ACS angiographic substudy, the use of early routine eptifibatide resulted in fewer angiographic procedural complications. These data provide support for the use of eptifibatide in the catheterization laboratory during high-risk cases merely to prevent angiographic procedural complications.
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Salarifar M, Mousavi M, Yousefpour N, Nematipour E, Kassaian SE, Poorhosseini H, Hajizeinali A, Alidoosti M, Aghajani H, Nozari Y, Amirzadegan A, Bozorgi A, Genab Y. Effect of Early Treatment With Tirofiban on Initial TIMI Grade 3 Flow of Patients With ST Elevation Myocardial Infarction. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e9641. [PMID: 24719720 PMCID: PMC3964438 DOI: 10.5812/ircmj.9641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Revised: 08/12/2013] [Accepted: 11/24/2013] [Indexed: 01/08/2023]
Abstract
Background: Before primary percutaneous coronary intervention (PCI) in patients with ST elevation myocardial infarction (STEMI), it is not clear whether a routine early administration of glycoprotein IIb/IIIa inhibitors in the emergency ward is beneficial or their administration in selected cases in the catheterization laboratory. Objectives: The present randomized clinical trial sought to investigate whether an earlier administration of Tirofiban could exert any impact on TIMI grade 3 flows and ST resolution in the electrocardiography of patients with STEMI before primary PCI. Materials and Methods: Patients with STEMI within twelve hours of symptom commencement were included if primary PCI was planned to be performed within ninety minutes of admission and excluded if they had contraindications for Tirofiban. Seventy patients were randomized to receive 25 μg/kg of bolus Tirofiban early in the emergency ward (the early Tirofiban group) in three minutes and 70 did not receive Tirofiban (the control group). The primary endpoint of the study was a Thrombolysis in Myocardial Infarction (TIMI) grade 3 flows on the initial angiogram. The study is registered as IRCT201105126463N1 in: www.irct.ir. Results: The study population had a mean age of 57.17 ± 10.09 years and included 79.3 % males. TIMI grade 3 flow was seen in 15 (21.4 %) patients of the Tirofiban group and 7 (10 %) of the control group (P = 0.06, odds ratio = 0.407, and 95 % confidence interval = 0.155-1.072). Complete ST resolution was seen in 30 (42.9 %) patients of the Tirofiban group and 34 (48.6 %) of the control group (P = 0.5). Conclusion: Although TIMI grade 3 flows trended to be higher in the patients who received early Tirofiban in the emergency ward, the difference did not constitute statistical significance and possible benefits, therefore, require further clarification.
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Affiliation(s)
- Mojtaba Salarifar
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Mehdi Mousavi
- Department of Cardiology, Alborz University of Medical Sciences, Shahid Rajai Hospital, Karaj, IR Iran
- Corresponding Author: Mehdi Mousavi, Department of Cardiology, Alborz University of Medical Sciences Shahid Rajai Hospital, Karaj, IR Iran, Tel: +98-9123053284, E-mail:
| | - Narges Yousefpour
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Ebrahim Nematipour
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Seyed Ebrahim Kassaian
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Hamidreza Poorhosseini
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Alimohammad Hajizeinali
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Mohammad Alidoosti
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Hassan Aghajani
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Younes Nozari
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Alireza Amirzadegan
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Ali Bozorgi
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
| | - Yaser Genab
- Department of Cardiology, Tehran University of Medical Sciences, Tehran Heart Center Hospital, Tehran, IR Iran
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Ducrocq G, Nejjari M, Juliard JM. Prise en charge en 2014 des syndromes coronaires aigus avec sus-décalage du segment ST. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0852-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Liu Y, Su Q, Li L. Safety and efficacy of early administration of tirofiban in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a meta-analysis. Chin Med J (Engl) 2014; 127:1126-1132. [PMID: 24622446 DOI: 10.3760/cma.j.issn.0366-6999.20131795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2025] Open
Abstract
BACKGROUND Tirofiban has been widely used as an adjunctive pharmacologic agent for revascularization in patients undergoing percutaneous coronary intervention, and the outcomes appear attractive. However, the potential benefits from early administration of tirofiban in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) remain unclear. METHODS We conducted a search in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials up to September 2012 without language restriction. A total of eight randomized trials (n = 1 577 patients) comparing early (emergency department or ambulance) versus late (catheterization laboratory) administration of tirofiban in STEMI patients undergoing PPCI were included in this meta-analysis. Risk ratio (RR) was computed from individual studies and pooled with random- or fixed-effect models. RESULTS There were no differences in post-procedural Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 and Corrected TIMI Frame Count (RR = 1.02, 95% confidence interval (CI): 0.99-1.05, P = 0.18; weighted mean difference (WMD) = -0.93, 95% CI: -5.37-3.52, P = 0.68, respectively) between the two groups. Similarly, there were no significant differences in the incidence of 30-day mortality (RR = 1.69, 95% CI: 0.69-4.13, P = 0.25) and re-myocardial infarction (RR = 0.71, 95% CI: 0.21-2.35, P = 0.57) between early and late administration of tirofiban. As to the safety end points, no significant difference was observed in hospital minor bleeding (RR = 1.08, 95% CI: 0.54-2.14, P = 0.83) and hospital and 30-day major bleeding between the two groups (RR = 0.98, 95% CI: 0.46-2.10, P = 0.96; RR = 1.32, 95% CI: 0.59-2.97, P = 0.49, respectively). CONCLUSIONS Early administration of tirofiban in patients undergoing PPCI for STEMI was safe, but no beneficial effects on post-procedural angiographic or clinical outcomes could be identified as compared with late administration. Besides the negative finding, more high-quality randomized clinical trials are still needed to explore the efficacy of adequate, earlier administration of tirofiban in patients undergoing PPCI.
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Affiliation(s)
- Yangchun Liu
- Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Guangxi Cardiovascular Institute, Nanning, Guangxi 530021, China
| | - Qiang Su
- Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Guangxi Cardiovascular Institute, Nanning, Guangxi 530021, China
| | - Lang Li
- Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Guangxi Cardiovascular Institute, Nanning, Guangxi 530021, China.
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Zhu J, Zhang T, Xie Q, Zhang J. Effects of Upstream Administration of Tirofiban Before Percutaneous Coronary Intervention on Spontaneous Reperfusion and Clinical Outcomes in Acute ST-Segment Elevation Myocardial Infarction. Angiology 2013; 66:70-8. [PMID: 24327765 DOI: 10.1177/0003319713514290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We assessed the effects of upstream administration of the glycoprotein IIb/IIIa inhibitor tirofiban before percutaneous coronary intervention (PCI) on spontaneous reperfusion (SR) of infarct-related artery (IRA) and the clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The incidence of SR of the IRA was significantly higher in the tirofiban group than in the no-tirofiban group (141 [36.5%] vs 21 [17.2%], P < .001). By multivariate logistic regression analysis, use of tirofiban (odds ratio 2.32, 95% confidence interval 1.25-4.31, P = .008) independently predicted the occurrence of SR. Kaplan-Meier survival analysis demonstrated that major adverse cardiovascular event-free survival was significantly higher in patients treated with tirofiban than in patients without tirofiban at 30-day (log rank = 11.65, P = .001) and 90-day follow-up (log rank = 16.79, P < .001). Upstream administration of tirofiban is significantly associated with increased SR of the IRA and favorable clinical prognosis in patients undergoing PCI for STEMI.
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Affiliation(s)
- Jianbing Zhu
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Tiantian Zhang
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qianqian Xie
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Junfeng Zhang
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Jia Z, Guo M, Zhang YQ, Liang HQ, Song Y. Short-term effect of upstream administration in comparison to deferred injection of tirofiban on patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. J Interv Cardiol 2013; 26:332-9. [PMID: 23844823 DOI: 10.1111/joic.12044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND High bolus dose tirofiban has been demonstrated to provide greater inhibition of platelet aggregation, but the most appropriate timing of its administration remains unknown. OBJECTIVES To evaluate the efficacy of upstream vs. deferred administration of tirofiban in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) on clinical outcomes. METHODS The 660 patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention were divided into upstream (n=330, administration of tirofiban to all patients in emergency room) and deferred groups (n=330, treatment of patients with large thrombus burden or no-reflow phenomenon in cardiac catheterization laboratory during PCI). The primary end-points were death, nonfatal myocardial infarction (MI), stent thrombosis (ST), revascularization of targeted vessels (TVR) or major adverse cardiac events (MACE) at 1 month and 6 months following PCI, with safety end-point at 7 days. RESULTS Compared with that of the deferred group, there was a significant increase of left ventricular ejection fraction (LVEF) in the upstream group within 7 days (55.5 ± 6.6% vs. 54.6 ± 7.9%, P=0.011). The rates of 7-day and 1-month MACE in the upstream group were lower than those in the deferred group (1.5% vs. 4.2%, 3.3% vs. 7.0%, P=0.037 and 0.034, respectively). However, there were higher tendencies for major and minor bleedings in the upstream group (1.8% vs. 0.9%, 2.7% vs. 1.5%, P=0.315 and 0.280, respectively). CONCLUSION To the Chinese patients with acute myocardial infarction undergoing primary PCI, upstream administration of tirofiban was slightly superior to deferred injection for short-term clinical outcomes.
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Affiliation(s)
- Zhi Jia
- TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, TEDA, Tianjin, China
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Montalescot G, Lassen JF, Hamm CW, Lapostolle F, Silvain J, ten Berg JM, Cantor WJ, Goodman SG, Licour M, Tsatsaris A, van't Hof AW. Ambulance or in-catheterization laboratory administration of ticagrelor for primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: rationale and design of the randomized, double-blind Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery (ATLANTIC) study. Am Heart J 2013; 165:515-22. [PMID: 23537967 DOI: 10.1016/j.ahj.2012.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 12/16/2012] [Indexed: 01/03/2023]
Abstract
Primary percutaneous coronary intervention (PCI) is the treatment of choice for patients presenting with acute ST-segment elevation myocardial infarction (STEMI). However, if catheterization facilities are not immediately available, the effectiveness of PCI can be affected by delays in transfer. Evidence suggests that antiplatelet therapy administered early, preferably in the ambulance during transfer, may provide better and earlier perfusion. Ticagrelor, a direct platelet P2Y12 receptor inhibitor, is indicated for the management of patients with acute coronary syndromes. The ATLANTIC study (NCT01347580; EudraCT 2011-000214-19) is a 30-day international, randomized, parallel-group, placebo-controlled study in male and female patients (aged ≥18 years) who are diagnosed as having STEMI, with intended primary PCI. In total, 1770 patients will be randomized immediately after diagnosis to prehospital administration of ticagrelor 180 mg followed by matching placebo administered in hospital, or prehospital administration of placebo followed by ticagrelor 180 mg administered in hospital. All patients will then receive ticagrelor 90 mg twice daily for 30 days. The coprimary end point is the percentage of patients reaching thrombolysis in myocardial infarction flow grade 3 in the infarct-related artery at initial angiography or achieving ≥70% ST-segment elevation resolution pre-PCI. The primary safety end point is major, life-threatening, or minor bleeding after ticagrelor administration. The results of this study may have an impact on future recommendations for treatment for patients with STEMI.
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Affiliation(s)
- Gilles Montalescot
- Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France.
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De Felice F, Fiorilli R, Parma A, Musto C, Nazzaro MS, Confessore P, Scappaticci M, Violini R. One-year clinical outcome of patients treated with or without abciximab in rescue coronary angioplasty. Int J Cardiol 2013; 163:294-298. [PMID: 21703701 DOI: 10.1016/j.ijcard.2011.06.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 04/23/2011] [Accepted: 06/06/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND The clinical results of abciximab administration during rescue angioplasty (PCI) are poorly investigated. METHODS We evaluated the outcome of 406 consecutive patients undergoing rescue PCI treated with (n=218) or without (n=188) abciximab and a clopidogrel loading dose of 300 mg. The end point was the incidence of major cardiac adverse events (MACE) defined as death, recurrent acute myocardial infarction (AMI) and target vessel revascularization at 30 days and 1 year. The predictors of MACE were also investigated. RESULTS No differences were found in MACE between the groups treated with or without abciximab at 30 days (15 and 20, p=0.67) and 1 year (23 and 29, p=0.85). Stepwise logistic regression analysis identified: cardiogenic shock (Odds Ratio [OR]=17.8, 95% confidence interval [CI] 5-99, p=0.0001), age (OR=1.099, 95% CI 1.04-1.15, p=0.0001), TIMI flow 0-1 after procedure (OR=5.51, 95% CI 1.72-17.6, p=0.004) as independent predictors of MACE at 30 days. Cox proportional hazards model identified: cardiogenic shock (adjusted hazard ratio [HR]=3.83, 95% confidence interval [CI] 1.76-8.35, p=0.01), age (HR=3.7, 95% CI 1.75-8.3, p=0.01), TIMI flow 0-1 after procedure (HR=1.04, 95% CI 1.01-1.07, p=0.001 as predictors of MACE at 1 year). After propensity score adjustments the predictors of MACE did not change. CONCLUSION There were no differences in MACE at 30 days and 1 year in patients treated with or without abciximab during rescue PCI after a clopidogrel loading dose of 300 mg. Cardiogenic shock, age and TIMI flow 0 and 1 after PCI were predictors of MACE.
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Affiliation(s)
- Francesco De Felice
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy.
| | - Rosario Fiorilli
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Antonio Parma
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Carmine Musto
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Marco Stefano Nazzaro
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Pierpaolo Confessore
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Massimiliano Scappaticci
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Roberto Violini
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
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Kelbæk H, Engstrøm T, Ahtarovski KA, Lønborg J, Vejlstrup N, Pedersen F, Holmvang L, Helqvist S, Saunamäki K, Jørgensen E, Clemmensen P, Kløvgaard L, Tilsted HH, Raungaard B, Ravkilde J, Aaroe J, Eggert S, Køber L. Deferred stent implantation in patients with ST-segment elevation myocardial infarction: a pilot study. EUROINTERVENTION 2013; 8:1126-33. [DOI: 10.4244/eijv8i10a175] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Optimal treatment of ACS patients: Issues and considerations for upstream antiplatelet therapy. Int J Cardiol 2013; 163:19-25. [DOI: 10.1016/j.ijcard.2011.10.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 10/18/2011] [Indexed: 11/21/2022]
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Xu Q, Yin J, Si LY. Efficacy and safety of early versus late glycoprotein IIb/IIIa inhibitors for PCI. Int J Cardiol 2013; 162:210-9. [DOI: 10.1016/j.ijcard.2012.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 05/28/2012] [Accepted: 06/07/2012] [Indexed: 11/30/2022]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:485-510. [PMID: 23256913 DOI: 10.1016/j.jacc.2012.11.018] [Citation(s) in RCA: 477] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:e362-425. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742cf6] [Citation(s) in RCA: 1119] [Impact Index Per Article: 86.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:529-55. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742c84] [Citation(s) in RCA: 1888] [Impact Index Per Article: 145.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:e78-e140. [PMID: 23256914 DOI: 10.1016/j.jacc.2012.11.019] [Citation(s) in RCA: 2263] [Impact Index Per Article: 174.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Silvain J, Vignalou JB, Beygui F, O'Connor SA, Barthélémy O, Boccara F, Ecollan P, Collet JP, Assayag P, Montalescot G. Impact of transfer time on mortality in acute coronary syndrome with ST-segment elevation treated by angioplasty. Arch Cardiovasc Dis 2012. [PMID: 23199619 DOI: 10.1016/j.acvd.2012.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND In primary percutaneous coronary intervention (pPCI), conflicting data exist on the relative importance of patient presentation time (time from symptom onset (SO) to first medical contact [FMC]) and transfer time (time from FMC to sheath insertion). OBJECTIVES To evaluate the impact of transfer time on mortality in an unselected ST-elevation myocardial infarction (STEMI) population treated with pPCI. METHODS In a well-organized urban network, using mobile intensive care units (MICU) whenever possible, the impact of transfer time on inhospital mortality was evaluated in 703 unselected consecutive STEMI patients transferred for pPCI. RESULTS Our STEMI population included patients with cardiogenic shock (5.3%) and out-of-hospital cardiac arrest (3.7%). Longer transfer times were found to be associated with a stepwise increase in mortality ranging from 2.99% in the first quartile (Q1) up to 8.65% in the fourth quartile (Q4) (P=0.005). This result was noted in patients presenting early (≤2h of SO, 0.96% for Q1 vs. 9.8% for Q4, P=0.006) but not in late presenters (>2h of SO, 7.00% for Q1 vs. 7.8% for Q4, P=0.85). After adjustment for confounding variables such as the severity of patients, the relationship between mortality and transfer time was no longer apparent. CONCLUSIONS In a well-organized urban network dedicated to pPCI, including unselected STEMI patients, transfer time does not appear to be a major contributor to mortality. The relationship of transfer time to mortality seems to be dependent on presentation time and patients' clinical severity.
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Affiliation(s)
- Johanne Silvain
- Institut de Cardiologie, Inserm, Pitié-Salpêtrière Hospital (AP-HP), Université Paris, Paris, France
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Abstract
Stenting in acute myocardial infarction (AMI) has the benefits of achieving acute optimal angiographic results and correcting residual dissection to decrease the incidence of restenosis and reocclusion. Studies have shown that percutaneous transluminal coronary angioplasty for primary treatment after AMI is superior to thrombolytic therapy regarding the restoration of normal coronary blood flow. Coronary stenting improves initial success rates, decreases the incidence of abrupt closure, and is associated with a reduced rate of restenosis. In the presence of thrombus-containing lesions, coronary stenting constitutes an effective therapeutic strategy, either after failure of initial angioplasty or electively as the primary procedure.
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Affiliation(s)
- Ahmed Magdy
- Cardiology Department, National Heart Institute, 44 Alsharifa Dina, Maadi, Cairo 11431, Egypt.
| | - Hisham Selim
- Cardiology Department, National Heart Institute, 44 Alsharifa Dina, Maadi, Cairo 11431, Egypt
| | - Mona Youssef
- Cardiology Department, National Heart Institute, 44 Alsharifa Dina, Maadi, Cairo 11431, Egypt
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2012; 79:453-95. [PMID: 22328235 DOI: 10.1002/ccd.23438] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Firoz T, Magee LA. Acute myocardial infarction in the obstetric patient. Obstet Med 2012; 5:50-7. [PMID: 27579136 PMCID: PMC4989614 DOI: 10.1258/om.2011.011080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2011] [Indexed: 12/22/2022] Open
Abstract
Acute myocardial infraction (AMI) in the obstetric patient is a rare event, although the incidence is rising due to advancing maternal age and pre-existing cardiac risk factors and medical co-morbidities. While atherosclerotic disease is the leading cause of AMI, coronary artery dissection is an important consideration in pregnancy and in the postpartum period. The physiological changes of pregnancy as well as pregnancy-specific risk factors can predispose the obstetric patient to AMI. Diagnosis of AMI can be challenging as symptoms may be atypical. Furthermore, diagnostic tests must be interpreted in the context of pregnancy. While the overall management of the obstetric patient with AMI is similar to that outside of pregnancy, drug therapy requires modification as some medications may be contraindicated in pregnancy and breastfeeding. There is limited information about prognosis and risk stratification but it is anticipated that future studies will address this issue.
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Affiliation(s)
- Tabassum Firoz
- Department of Medicine, University of British Columbia, Vancouver, British Columbia,Canada
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Anticoagulant for primary percutaneous coronary intervention – the last dance for unfractionated heparin? Arch Cardiovasc Dis 2012; 105:259-61. [DOI: 10.1016/j.acvd.2012.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 03/11/2012] [Indexed: 12/13/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary. J Am Coll Cardiol 2011. [DOI: 10.1016/j.jacc.2011.08.006] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:2574-609. [PMID: 22064598 DOI: 10.1161/cir.0b013e31823a5596] [Citation(s) in RCA: 387] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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