11 research outputs found
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
Results of Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) trial
BACKGROUND: Restenosis after percutaneous coronary intervention (PCI) is a major problem affecting 15% to 30% of patients after stent placement. No oral agent has shown a beneficial effect on restenosis or on associated major adverse cardiovascular events. In limited trials, the oral agent tranilast has been shown to decrease the frequency of angiographic restenosis after PCI. METHODS AND RESULTS: In this double-blind, randomized, placebo-controlled trial of tranilast (300 and 450 mg BID for 1 or 3 months), 11 484 patients were enrolled. Enrollment and drug were initiated within 4 hours after successful PCI of at least 1 vessel. The primary end point was the first occurrence of death, myocardial infarction, or ischemia-driven target vessel revascularization within 9 months and was 15.8% in the placebo group and 15.5% to 16.1% in the tranilast groups (P=0.77 to 0.81). Myocardial infarction was the only component of major adverse cardiovascular events to show some evidence of a reduction with tranilast (450 mg BID for 3 months): 1.1% versus 1.8% with placebo (P=0.061 for intent-to-treat population). The primary reason for not completing treatment was > or =1 hepatic laboratory test abnormality (11.4% versus 0.2% with placebo, P<0.01). In the angiographic substudy composed of 2018 patients, minimal lumen diameter (MLD) was measured by quantitative coronary angiography. At follow-up, MLD was 1.76+/-0.77 mm in the placebo group, which was not different from MLD in the tranilast groups (1.72 to 1.78+/-0.76 to 80 mm, P=0.49 to 0.89). In a subset of these patients (n=1107), intravascular ultrasound was performed at follow-up. Plaque volume was not different between the placebo and tranilast groups (39.3 versus 37.5 to 46.1 mm(3), respectively; P=0.16 to 0.72). CONCLUSIONS: Tranilast does not improve the quantitative measures of restenosis (angiographic and intravascular ultrasound) or its clinical sequelae
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
1060-80 Female sex: A more important prognostic marker than treatment assignment or comorbid conditions among patients with acute myocardial infarction in the GUSTO V trial
Risk of stroke associated with abciximab among patients undergoing percutaneous coronary intervention
CONTEXT: Abciximab, a potent inhibitor of the platelet glycoprotein IIb/IIIa receptor, reduces thrombotic complications in patients undergoing percutaneous coronary inter
Patients with acute coronary syndromes without persistent ST elevation undergoing percutaneous coronary intervention benefit most from early intervention with protection by a glycoprotein IIb/IIIa receptor blocker.
BACKGROUND: Many patients with acute coronary syndromes are offered percutaneous coronary intervention. However, the appropriate indications for, and optimal timing of, such procedures are uncertain. We analysed timing of intervention and associated events (death and myocardial infarction) in the PURSUIT trial in which 9461 patients received a platelet glycoprotein IIb/IIIa inhibitor, eptifibatide, or placebo for 72 h. Other treatment was left to the investigators. 2430 patients underwent percutaneous coronary intervention within 30 days. Four groups were distinguished, who underwent percutaneous coronary intervention on day 1; on days 2 or 3; at 4 to 7 days; or between 8 until 30 days, for eptifibatide- and placebo-treated patients. RESULTS: The four groups treated with placebo demonstrated total 30-
Early percutaneous coronary intervention, platelet inhibition with eptifibatide, and clinical outcomes in patients with acute coronary syndromes. PURSUIT Investigators
BACKGROUND: Platelet glycoprotein (GP) IIb/IIIa antagonists prevent the
composite end point of death or myocardial infarction (MI) in patients
with acute coronary syndromes. There is uncertainty about whether this
effect is confined to patients who have percutaneous coronary
interventions (PCIs) and whether PCIs further prevent death or MI in
patients already treated with GP IIb/IIIa antagonists. METHODS AND
RESULTS: PURSUIT patients were treated with the GP IIb/IIIa antagonist
eptifibatide or placebo; PCIs were performed according to physician
practices. In 2253 of 9641 patients (23.4%), PCI was performed by 30 days.
Early (<72 hours) PCI was performed in 1228 (12.7%). In 34 placebo
patients (5.5%) and 10 treated with eptifibatide (1.7%) (P=0.001), MI
preceded early PCI. In patients censored for PCI across the 30-day period,
there was a significant reduction in the primary composite end point in
eptifibatide patients (P=0.035). Eptifibatide reduced 30-day events in
patients who had early PCI (11.6% versus 16.7%, P=0.01) and in patients
who did not (14.6% versus 15.6%, P=0.23). After adjustment for PCI
propensity, there was no evidence that eptifibatide treatment effect
differed between patients with or without early PCI (P for
interaction=0.634). PCI was not associated with a reduction of the primary
composite end point but was associated with a reduced (nonspecified)
composite of death or Q-wave MI. This association disappeared after
adjustment for propensity for early PCI. CONCLUSIONS: Eptifibatide reduced
the composite rates of death or MI in PCI patients and those managed
conservatively
Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease.The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators
BACKGROUND: A proportion of patients who present with suspected acute
coronary syndrome (ACS) are found to have insignificant coronary artery
disease (CAD) during coronary angiography, but these patients have not
been well characterized. METHODS AND RESULTS: Of the 5767 patients with
non-ST-segment elevation ACS who were enrolled in the Platelet
Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using
Integrilin (Eptifibatide) Therapy (PURSUIT) trial and who underwent
in-hospital angiography, 88% had significant CAD (any stenosis >50%), 6%
had mild CAD (any stenosis >0% to </=50%), and 6% had no CAD (no stenosis
identified). The frequency of death or nonfatal myocardial infarction at
30 days was reduced with eptifibatide treatment in patients with
significant CAD (18.3% versus 15.6% for placebo, P=0.006) but not in those
with mild CAD (6.6% versus 5.4%, P=0.62) and with no CAD (3.0% versus 1.
2%, P=0.28). We identified independent baseline predictors of
insignificant CAD (mild or no CAD) and used them to develop a simple
predictive nomogram of the probability of insignificant CAD for use at
hospital presentation. This nomogram was validated in a separate
population of patients with non-ST-segment elevation ACS. CONCLUSIONS:
Patients with suspected ACS found to have insignificant CAD have a low
risk of adverse outcomes, do not appear to benefit from treatment with
eptifibatide, and can be predicted with a simple nomogram drawn from
baseline characteristics. Because patients with significant CAD appear to
have an enhanced benefit from eptifibatide treatment, the predictive
nomogram developed can be used to determine indications for glycoprotein
IIb/IIIa blockade
Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators
BACKGROUND: Appropriate treatment policies should include an accurate
estimate of a patient's baseline risk. Risk modeling to date has been
underutilized in patients with acute coronary syndromes without persistent
ST-segment elevation. METHODS AND RESULTS: We analyzed the relation
between baseline characteristics and the 30-day incidence of death and the
composite of death or myocardial (re)infarction in 9461 patients with
acute coronary syndromes without persistent ST-segment elevation enrolled
in the PURSUIT trial [Platelet glycoprotein IIb/IIIa in Unstable angina:
Receptor Suppression Using Integrilin (eptifibatide) Therapy]. Variables
examined included demographics, history, hemodynamic condition, and
symptom duration. Risk models were created with multivariable logistic
regression and validated by bootstrapping techniques. There was a 3.6%
mortality rate and 11.4% infarction rate by 30 days. More than 20
significant predictors for mortality and for the composite end point were
identified. The most important baseline determinants of death were age
(adjusted chi(2)=95), heart rate (chi(2)=32), systolic blood pressure
(chi(2)=20), ST-segment depression (chi(2)=20), signs of heart failure
(chi(2)=18), and cardiac enzymes (chi(2)=15). Determinants of mortality
were generally also predictive of death or myocardial (re)infarction.
Differences were observed, however, in the relative prognostic importance
of predictive variables for mortality alone or the composite end point;
for example, sex was a more important determinant of the composite end
point (chi(2)=21) than of death alone (chi(2)=10). The accuracy of the
prediction of the composite end point was less than that of mortality
(C-index 0.67 versus 0.81). CONCLUSIONS: The occurrence of adverse events
after presentation with acute coronary syndromes is affected by multiple
factors. These factors should be considered in the clinical
decision-making process