More rapid, complete, and stable coronary thrombolysis with bolus administration of reteplase compared with alteplase infusion in acute myocardial infarction. RAPID Investigators

Background Early restoration and maintenance of normal (TIMI 3) blood flow during acute myocardial infarction is critical for optimal preservation of left ventricular function and survival. Recombinant plasminogen activator (r-PA, reteplase) is a nonglycosylated deletion mutant of wild-type tissue-type plasminogen activator (TPA) that has been shown to achieve more rapid and complete thrombolysis compared with other plasminogen activators in animal models. Methods and Results The RAPID Trial was designed to test the hypothesis that bolus administration of one or more dosage regimens of r-PA was superior to standard-dose alteplase (TPA) in achieving infarct-related artery patency 90 minutes after initiation of treatment. Six hundred six patients with acute myocardial infarction were randomized to one of four treatment arms: (1) TPA 100 mg IV over 3 hours, (2) r-PA as a 15-MU single bolus, (3) r-PA as a 10-MU bolus followed by 5 MU 30 minutes later, or (4) r-PA as a 10-MU bolus followed by 10 MU 30 minutes later. Coronary arteriography was performed at 30, 60, and 90 minutes after initiation of treatment and at hospital discharge. The 10+10-MU r-PA group achieved better 90-minute and 5- to 14-day TIMI 3 flow (63% [CI, 55% to 71%] versus 49% [41% to 57%], P =.019, and 88% [82% to 94%] versus 71% [63% to 79%], P &lt;.001, respectively) than the TPA group. The TIMI 3 flow in the 10+10-MU r-PA group at 60 minutes was equivalent to that in the TPA group at 90 minutes (51 versus 49%). Global ejection fraction and regional wall motion in the 10+10-MU r-PA group were superior to those of the TPA group at hospital discharge (53±1.3% versus 49±1.3%, P =.034; −2.19±0.12 versus −2.61±0.13 SD per chord, P =.02, respectively). The 15-MU and 10+5-MU r-PA patency and left ventricular function results were similar to those of the TPA and inferior to those of the 10+10-MU r-PA group. Bleeding complications were similar between the groups. Conclusions r-PA given as a double bolus of 10+10 MU achieves more rapid, complete, and sustained thrombolysis of the infarct-related artery than standard-dose TPA, without an apparent increased risk of complications. This was associated with improved global and regional left ventricular function at hospital discharge. </jats:p

<特集I>西塚泰美元学長を偲んで

Changes in intracoronary volume reflect the hemodynamic significance of progression or regression of diffuse coronary artery disease where intracoronary catheters cannot be applied for direct measurements due to small vessel dimensions. We have validated the videodensitometric measurement of intracoronary volume with epoxy casts of postmortem human coronary arteries. The volume of 31 coronary segments (cross-sectional areas in a range of 2-13 mm2) measured by fluid-filling using a precision dispenser was compared with the respective single plane intracoronary volume assessments obtained by the videodensitometric algorithm of the new generation Cardiovascular Angiography Analysis System (CAAS II). The true and measured values of volume were compared by calculation of the mean of the signed differences +/- standard deviation and by linear regression analysis. Videodensitometric measurement of intracoronary volume correlate well with fluid-filling of human coronary artery casts (correlation coefficient: r = 0.99, y = 1.96 +/- 0.99x, standard error of estimate: SEE = 3.96) with a significant trend towards overestimation of true volume values (mean difference = 1.73 +/- 3.64 mm3, P < 0.05). Intracoronary volume estimations can be used to measure changes of luminal dimensions of coronary arteries and may offer a new approach to assessment of progression or regression of diffuse coronary artery disease

An update on the management and outcomes of cancer patients with severe aortic stenosis

Objectives: We compared the outcomes of aortic valve replacement (AVR) by transcatheter (TAVR) and surgical (SAVR) routes with those of optimal medical management in patients with cancer and severe aortic stenosis (AS). Background: Cancer therapy requires optimal cardiac output; however, the treatment of AS in cancer patients is not established. Methods: Cancer patients with severe AS during January 2009 through February 2018 at a large cancer center were identified. Demographic and clinical characteristics including previous or active cancer diagnosis, history of chest radiotherapy, AS treatment, and survival were collected. Univariate Cox proportional hazards regression, the Kaplan–Meier analysis, and log-rank tests were used to compare overall survival (OS) between AS treatment groups. Results: Sixty-five cancer patients with severe AS were identified; 28 received optimal medical treatment alone, 30 received TAVR, and seven received SAVR. The patients were predominantly male (n = 44, 68%) with a mean age of 71.17 years. The median OS was 9.87 months, and the most common cause of death was cancer (n = 29, 94% of deaths). AVR was associated with a lower risk of death than no AVR (hazard ratio [HR] 0.38, P = 0.007), and patients who underwent TAVR (HR 0.36, P = 0.01) had better survival than those with no AVR. Malignancy type, stage, and treatment were not associated with OS. Conclusions: Patients with cancer and severe AS who underwent AVR, predominantly TAVR, experienced better survival than those who had no AVR regardless of cancer type or cancer treatment. TAVR may be considered in patients with cancer and AS. © 2018 Wiley Periodicals, Inc