97 research outputs found
Performance of an automated real-time ST-segment analysis program to detect coronary occlusion and reperfusion
Platelet Glycoprotein IIb/IIIa Receptor Inhibition in Non-ST-Elevation Acute Coronary Syndromes
BACKGROUND: Glycoprotein (GP) IIb/IIIa receptor blockers prevent
life-threatening cardiac complications in patients with acute coronary
syndromes without ST-segment elevation and protect against thrombotic
complications associated with percutaneous coronary interventions (PCIs).
The question arises as to whether these 2 beneficial effects are
independent and additive. METHODS AND RESULTS: We analyzed data from the
CAPTURE, PURSUIT, and PRISM-PLUS randomized trials, which studied the
effects of the GP IIb/IIIa inhibitors abciximab, eptifibatide, and
tirofiban, respectively, in acute coronary syndrome patients without
persistent ST-segment elevation, with a period of study drug infusion
before a possible PCI. During the period of pharmacological treatment,
each trial demonstrated a significant reduction in the rate of death or
nonfatal myocardial infarction in patients randomized to the GP IIb/IIIa
inhibitor compared with placebo. The 3 trials combined showed a 2.5% event
rate in this period in the GP IIb/IIIa inhibitor group (N=6125) versus
3.8% in placebo (N=6171), which implies a 34% relative reduction
(P<0.001). During study medication, a PCI was performed in 1358 patients
assigned GP IIb/IIIa inhibition and 1396 placebo patients. The event rate
during the first 48 hours after PCI was also significantly lower in the GP
IIb/IIIa inhibitor group (4. 9% versus 8.0%; 41% reduction; P<0.001). No
further benefit or rebound effect was observed beyond 48 hours after the
PCI. CONCLUSIONS: There is conclusive evidence of an early benefit of GP
IIb/IIIa inhibitors during medical treatment in patients with acute
coronary syndromes without persistent ST-segment elevation. In addition,
in patients subsequently undergoing PCI, GP IIb/IIIa inhibition protects
against myocardial damage associated with the intervention
Risk Factors for In-hospital Nonhemorrhagic Stroke in Patients With Acute Myocardial Infarction Treated With Thrombolysis: Results from GUSTO-I
BACKGROUND: Nonhemorrhagic stroke occurs in 0.1% to 1.3% of patients with
acute myocardial infarction who are treated with thrombolysis, with
substantial associated mortality and morbidity. Little is known about the
risk factors for its occurrence. METHODS AND RESULTS: We studied the 247
patients with nonhemorrhagic stroke who were randomly assigned to one of
four thrombolytic regimens within 6 hours of symptom onset in the GUSTO-I
trial. We assessed the univariable and multivariable baseline risk factors
for nonhemorrhagic stroke and created a scoring nomogram from the baseline
multivariable modeling. We used time-dependent Cox modeling to determine
multivariable in-hospital predictors of nonhemorrhagic stroke. Baseline
and in-hospital predictors were then combined to determine the overall
predictors of nonhemorrhagic stroke. Of the 247 patients, 42 (17%) died
and another 98 (40%) were disabled by 30-day follow-up. Older age was the
most important baseline clinical predictor of nonhemorrhagic stroke,
followed by higher heart rate, history of stroke or transient ischemic
attack, diabetes, previous angina, and history of hypertension. These
factors remained statistically significant predictors in the combined
model, along with worse Killip class, coronary angiography, bypass
surgery, and atrial fibrillation/flutter. CONCLUSIONS: Nonhemorrhagic
stroke is a serious event in patients with acute myocardial infarction who
are treated with thrombolytic, antithrombin, and antiplatelet therapy. We
developed a simple nomogram that can predict the risk of nonhemorrhagic
stroke on the basis of baseline clinical characteristics. Prophylactic
anticoagulation may be an important treatment strategy for patients with
high probability for nonhemorrhagic stroke, but further study is needed
Individual risk assessment for intracranial haemorrhage during thrombolytic therapy
Thrombolytic therapy improves outcome in patients with myocardial infarction but is associated with an increased risk of intracranial haemorrhage. For some patients, this risk may outweigh the potential benefits of thrombolytic treatment. Using data from other studies, we developed a model for the assessment of an individual's risk of intracranial haemorrhage during thrombolysis.
Data were available from 150 patients with documented intracranial haemorrhage and 294 matched controls. 49 patients with intracranial haemorrhage and 122 controls had been treated with streptokinase, whereas 88 cases and 148 controls had received alteplase. By multivariate analysis, four factors were identified as independent predictors of intracranial haemorrhage; age over 65 years (odds ratio 2·2 [95% Cl 1·4–3·5]), body weight below 70 kg (2·1 [1·3–3·2]), hypertension on hospital admission (2·0 [1·2–3·2]), and administration of alteplase (1·6 [1·0–2·5]).
If the overall incidence of intracranial haemorrhage is assumed to be 0·75%, patients without risk factors who receive streptokinase have a 0·26% probability of intracranial haemorrhage. The risk is 0·96%, 1·32%, and 2·17% in patients with one, two, or three risk factors, respectively. We present a model for individual risk assessment that can be used easily in clinical practice
Transcript of The Dory Derby Accident
This story is an excerpt from a longer interview that was collected as part of the Launching through the Surf: The Dory Fleet of Pacific City project. In this story, Don Grotjohn recounts an accident that occurred during a Dory Derby competition
Sustained ventricular arrhythmias among patients with acute coronary syndromes with no ST-segment elevation: incidence, predictors, and outcomes
BACKGROUND: The prognosis of ventricular arrhythmias among patients with non-ST-elevation acute coronary syndromes is unknown. We studied the incidence, predictors, and outcomes of sustained ventricular arrhythmias in 4 large randomized trials of such patients. METHODS AND RESULTS: We pooled the datasets of the Global Use of Streptokinase and tPA for Occluded Arteries (GUSTO)-IIb, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT), Platelet IIb/IIIa Antagonism for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network (PARAGON)-A, and PARAGON-B trials (n=26 416). We identified independent predictors of ventricular fibrillation (VF) and ventricular tachycardia (VT) and compared the 30-day and 6-month mortality rates of patients who did (n=552) and did not (n=25 864) develop these arrhythmias during the index hospitalization. Independent predictors of in-hospital VF included prior hypertension, chronic obstructive pulmonary disease, prior myocardial infarction, and ST-segment changes at presentation. Except for hypertension, these variables also independently predicted in-hospital VT. In Cox proportional-hazards modeling, in-hospital VF and VT were independently associated with 30-day mortality (hazard ratio [HR], 23.2 [95% CI, 18.1 to 29.8] for VF and HR, 7.6 [95% CI, 5.5 to 10.4] for VT) and 6-month mortality (HR, 14.8 [95% CI, 12.1 to 18.3] for VF and HR, 5.0 [95% CI, 3.8 to 6.5] for VT). These differences remained significant after excluding patients with heart failure or cardiogenic shock and those who died <24 hours after enrollment. CONCLUSIONS: Despite the use of effective therapies for non-ST-elevation acute coronary syndromes, ventricular arrhythmias in this setting are associated with increased 30-day and 6-month mortality. More effective therapies are needed to improve the survival of patients with these arrhythmias
Cost effectiveness of thrombolytic therapy with tissue plasminogen activator as compared with streptokinase for acute myocardial infarction
BACKGROUND. Patients with acute myocardial infarction who were treated with accelerated tissue plasminogen activator (t-PA) (given over a period of 1 1/2 hours rather than the conventional 3 hours, and with two thirds of the dose given in the first 30 minutes) had a 30-day mortality that was 15 percent lower than that of pati
Stroke in Patients With Acute Coronary Syndromes: Incidence and Outcomes in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial
BACKGROUND: The incidence of stroke in patients with acute coronary
syndromes has not been clearly defined because few trials in this patient
population have been large enough to provide stable estimates of stroke
rates. METHODS AND RESULTS: We studied the 10 948 patients with acute
coronary syndromes without persistent ST-segment elevation who were
randomly assigned to placebo or the platelet glycoprotein IIb/IIIa
receptor inhibitor eptifibatide in the Platelet Glycoprotein IIb/IIIa in
Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT)
trial to determine stroke rates, stroke types, clinical outcomes in
patients with stroke, and independent baseline clinical predictors for
nonhemorrhagic stroke. Stroke occurred in 79 (0.7%) patients, with 66
(0.6%) nonhemorrhagic, 6 intracranial hemorrhages, 3 cerebral infarctions
with hemorrhagic conversion, and 4 of uncertain cause. There were no
differences in stroke rates between patients who received placebo and
those assigned high-dose eptifibatide (odds ratios and 95% confidence
intervals 0.82 [0.59, 1.14] and 0.70 [0.49, 0.99], respectively). Of the
79 patients with stroke, 17 (22%) died within 30 days, and another 26
(32%) were disabled by hospital discharge or 30 days, whichever came
first. Higher heart rate was the most important baseline clinical
predictor of nonhemorrhagic stroke, followed by older age, prior anterior
myocardial infarction, prior stroke or transient ischemic attack, and
diabetes mellitus. These factors were used to develop a simple scoring
nomogram that can predict the risk of nonhemorrhagic stroke. CONCLUSIONS:
Stro
Creatine kinase-MB elevation after percutaneous coronary intervention predicts adverse outcomes in patients with acute coronary syndromes.
AIM: To study the relationship between outcomes and peak creatine kinase (CK)-MB levels after percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation acute coronar
Difference in countries' use of resources and clinical outcome for patients with cardiogenic shock after myocardial infarction: results from the GUSTO trial
BACKGROUND: Use of aggressive and invasive interventions is more common in the USA than in other countries. We have compared use of resources for patients with cardiogenic shock after myocardial infarction in the USA and in other countries, and assessed the association between use of resources and clinical outcomes. METHODS: We analysed data for patients with cardiogenic shock after myocardial infarction who were enrolled in the GUSTO-I trial (1891 treated in the USA, 1081 treated in other countries). Patients were randomly assigned combinations of streptokinase, heparin, and accelerated tissue-plasminogen activator (t-PA), then decisions about further interventions were left to the discretion of the attending physician. The interventions included in our analysis were: pulmonary-artery catheterisation, cardiac catheterisation, intravenous inotropic agents, ventilatory support, intra-aortic balloon counterpulsation (IABP), percutaneous transluminal coronary angioplasty (PTCA), and coronary bypass graft surgery (CABG). The primary outcome measure was death from any cause at 30 days of follow-up. FINDINGS: Patients who were treated in the USA were significantly younger than those treated elsewhere (median 68 [IQR 59-75] vs 70 [62-76], p < 0.001), a smaller proportion had anterior infarction (49 vs 53%, p < 0.001), and they had a shorter time to treatment (mean 3.1 vs 3.3 h, p < 0.001). Aggressive diagnostic and therapeutic procedures were used more commonly in the USA than in the other countries: cardiac catheterisation (58 vs 23%); IABP (35 vs 7%); right-heart catheterisation (57 vs 22%); and ventilatory support (54 vs 38%). 483 (26%) of the patients treated in the USA underwent PTCA, compared with 82 (8%) patients in oth
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