A comparison of recombinant Hirudin with Heparin for the treatment of acute coronary syndromes. The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb Investigators

BACKGROUND: Thrombin has a pivotal role in the pathogenesis of acute coronary thrombosis. We compared the clinical efficacy of a potent, direct thrombin inhibitor, recombinant hirudin, with that of heparin (an indirect antithrombin agent) in patients with unstable angina or acute myocardial infarction. METHODS: At 373 hospitals in 13 countries, 12,142 patients with acute coronary syndromes were randomly assigned to 72 ho

Genezen is beter dan voorkomen

In de tweede helft van de vorige eeuw waren hart en vaatziekten de belangrijkste doodsoorzaak in Nederland. Dit is lang zo gebleven, maar na een piek rond 1970 is de sterfte aan hart en vaatziekten, gecorrigeerd voor de leeftijd, gedaald en sinds enkele jaren staan hart en vaatziekten op de tweede plaats wat betreft de sterfte percentages. (figuur 1) Dit is een verdienste van de cardiologie en de vasculaire geneeskunde. De levensverwachting in Nederland en in andere westerse landen is in die jaren belangrijk toegenomen. Dat komt vooral door enorme verbeteringen in de preventie en behandeling van hart en vaatziekten in 40 jaar. De helft van deze winst komt door betere preventie en de helft door betere behandeling van de ziekte. Afscheidsrede Prof. dr. Maarten L. Simoons hoogleraar Cardiologie Erasmus Universiteit Rotterdam, uitgesproken 17 december 201

Chronic stable coronary artery disease: drugs vs. revascularization

Coronary artery disease remains the leading cause of mortality in most industrialized countries, although age-standardized mortality related to coronary artery disease (CAD) has decreased by more than 40% during the last two decades. Coronary atherosclerosis may cause angina pectoris, myocardial infarction, heart failure, arrhythmia, and sudden death. Medical management of atherosclerosis and its manifestation aims at retardation of progression of plaque formation, prevention of plaque rupture, and subsequent events and treatment of symptoms, when these occur as well as treatment of the sequelae of the disease. Revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) is performed as treatment of flow-limiting coronary stenosis to reduce myocardial ischaemia. In high-risk patients with acute coronary syndromes (ACS), a routine invasive strategy with revascularization in most patients provides the best outcome with a significant reduction in death and myocardial infarction compared with an initial conservative strategy. Conversely, the benefit of revascularization among patients with chronic stable CAD has been called into question. This review will provide information that revascularization exerts favourable effects on symptoms, quality of life, exercise capacity, and survival, particularly in those with extensive CAD and documented moderate-to-severe ischaemia. Accordingly, CABG and PCI should be considered a valuable adjunct rather than an alternative to medical therap

A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction

BACKGROUND: Among physicians who treat patients with acute myocardial infarction, there is controversy about the magnitude of the clinical benefit of primary (i.e., immediate) coronary angioplasty as compared with thrombolytic therapy. METHODS: As part of the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) trial, we randomly assigned, 1138 patients from 57 hospitals who presented within 12 hours of acute myocardial infarction (with ST-segment elevation on the electrocardiogram) to primary angioplasty or accelerated thrombolytic therapy with recombinant tissue plasminogen activator (t-PA). We also randomly assigned 1012 patients to heparin or hirudin treatment in a factorial design. The primary study end point was a composite outcome of death, nonfatal reinfarction, and nonfatal disabling stroke at 30 days. RESULTS: The incidence of the primary end point in the angioplasty and t-PA groups was 9.6 percent and 13.7 percent, respectively (odds ratio, 0.67; 95 percent confidence interval, 0.47 to 0.97; P = 0.033). Death occurred in 5.7 percent of the patients assigned to angioplasty and 7.0 percent of those assigned to t-PA (P=0.37), reinfarction in 4.5 percent and 6.5 percent (P=0.13), and disabling stroke in 0.2 percent and 0.9 percent (P=0.11). At six months, there was no significant difference in the incidence of the composite outcome (13.3 percent vs. 15.7 percent, P not significant) [corrected]. The primary end point was observed in 10.6 percent of the patients in the angioplasty group assigned to heparin and 8.2 percent of those assigned to hirudin (P=0.37). CONCLUSIONS: This trial suggests that angioplasty provides a small-to-moderate, short-term clinical advantage over thrombolytic therapy with t-PA. Primary angioplasty, when it can be accomplished promptly at experienced centers, should be considered an excellent alternative method for myocardial reperfusion

Toward the optimal lead system and optimal criteria for exercise electrocardiography

To define the optimal lead system for exercise electrocardiography, data of the whole body surface potential distribution were analyzed in 25 normal subjects and in 25 patients with coronary artery disease at rest and during exercise. All patients had a normal electrocardiogram at rest. The sensitivity of the standard chest leads was 60 percent; it improved to 84 percent with the body surface map whereas both methods had a 100 percent specificity. On the basis of these data, and reports from other centers, it is concluded that a single bipolar lead from the right subclavian area to lead V5 is adequate in those laboratories that are restricted to testing subjects with a normal electrocardiogram at rest. In patients with a previous infarction or other abnormalities in the electrocardiogram at rest three (pseudo) orthogonal leads or several standard leads are necessary. Recommendations for optimal measurements from the exercise electrocardiogram are based on quantitative computer analysis of the selected leads in larger groups of patients. Best results were obtained with a combination of S-T amplitude, S-T slope and heart rate. The improvement in sensitivity from 50 percent with visual analysis to 85 percent with computer was similar to that obtained with body surface mapping. Changes of the P wave and QRS complex during exercise appeared to be of little diagnostic value. The pathophysiologic mechanisms that contribute to the changes of the electrocardiogram during exercise are discussed

Should all patients with an acute myocardial infarction be referred for direct PTCA?

All randomised comparisons have shown that direct PTCA is superior to thrombolysis in patients with AMI. Yet the choice of treatment strategy should depend on the careful evaluation of the risk/benefit of treatment. Issues unrelated to this assessment will most likely influence the selection of treatment in daily practice. Two algorithms have been proposed which differ in the primary selection or triage criterion (area at risk versus time interval). Based upon local and regional factors, one or the other may be chosen. The role of rescue and systematic PTCA after thrombolysis needs further elucidation. At present, it cannot be proposed as a standard treatment