Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Publicidade Direta ao Consumidor , Prescrições de Medicamentos/estatística & dados numéricos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/economia , Feminino , Humanos , Itália , Masculino , Estudos Prospectivos , Acidente Vascular Cerebral/prevenção & controleRESUMO
AIM: To assess the prevalence, risk and management of hyperglycemia in patients with acute coronary syndrome (ACS). DESIGN: a multicenter prospective observational study of a representative sample of patients with ACS consecutively admitted to intensive cardiac care units (ICCU). SETTING: 31 out of 61 ICCUs in Lombardy, the most heavily populated Italian region. From May 2009 to April 2010 1260 patients (69.4% male; mean age 68 ± 13 years) were included in the study: 301 (23.9%) were known diabetic patients (D) and 265 (21.0%) had hyperglycemia (H) (blood glucose >180 mg/dL) at hospital admission, 174 with a history of diabetes (D+H+) and 91 without (D-H+). On the first day after admission intravenous insulin infusion was prescribed to 72 D+H+ (41.4%) and 10 D-H+ (11.0%), according to different protocols. Approximately one third of D+H+ patients (59) and one fifth (17) of D-H+ maintained mean blood glucose higher than 180 mg/dL during the first day in the ICCU. Patients with diabetes or hyperglycemia had a higher incidence of major adverse cardiovascular events or death in hospital. However, at multivariable analysis neither diabetes nor blood glucose at admission was associated with a poor prognosis whereas mean blood glucose on the first day was an independent negative prognostic predictor (OR 1.010, 95% CI 1.002-1.018, p = 0.016). CONCLUSION: Hyperglycemia is frequent in patients with ACS and is independently associated with a poor in-hospital prognosis if it persists in first day. Unfortunately, however, this condition is still poorly treated, with far from optimal blood glucose control.
Assuntos
Síndrome Coronariana Aguda/complicações , Hiperglicemia/tratamento farmacológico , Insulina/uso terapêutico , Idoso , Glicemia/análise , Unidades de Cuidados Coronarianos , Complicações do Diabetes/epidemiologia , Diabetes Mellitus , Feminino , Humanos , Hiperglicemia/sangue , Hiperglicemia/complicações , Itália , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: we evaluated the prognostic role of circulating cardiovascular biomarkers in patients with a history of recent atrial fibrillation (AF). BACKGROUND: predicting long-term maintenance of sinus rhythm in patients with AF is difficult. METHODS: plasma concentrations of three specific cardiac markers [high-sensitivity troponin T (hsTnT), N-terminal probrain natriuretic peptide (NT-proBNP) and mid-regional proatrial natriuretic peptide (MR-proANP)] and three stable fragments of vasoactive peptides [mid-regional proadrenomedullin (MR-proADM), copeptin (CT-proAVP) and CT-proendothelin-1 (CT-proET-1)] were measured at baseline and after 6 and 12 months in 382 patients enrolled in the GISSI-AF study, a prospective randomized trial to determine the effect of valsartan to reduce the recurrence of AF. The association between these markers, clinical characteristics and recurrence of AF was tested by univariate and multivariate Cox models. RESULTS: mean patient age was 68 ± 9 years (37.2% females). A total of 84.8% of patients had a history of hypertension. In total, 59.7% qualified for history of AF because of successful cardioversion, 11.8% because of two or more episodes of AF in the 6 months preceding randomization and 28.5% because of both. Patients in AF at 6 or 12 months (203 (53.1%) with first recurrence) had significantly higher concentrations of most biomarkers. Despite low baseline levels, higher concentrations of hsTnT {adjusted hazard ratio (HR) [95% confidence intervals (CIs) for 1 SD increment] (1.15 [1.04-1.28], P = 0.007), MR-proANP (1.15 [1.01-1.30], P = 0.04), NT-proBNP (1.24 [1.11-1.39], P = 0.0001) and CT-proET-1 (1.16 [1.01-1.33], P = 0.03) independently predicted higher risk of a first recurrence of AF. Changes over time of MR-proANP tended to predict subsequent recurrence (adjusted HR [95%CI]) (1.53 [0.98-2.37], P = 0.06). CONCLUSION: circulating markers of cardiomyocyte injury/strain and endothelin are related to recurrence of AF in patients in sinus rhythm with a history of recent AF.
Assuntos
Fibrilação Atrial/diagnóstico , Biomarcadores/sangue , Idoso , Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Fibrilação Atrial/sangue , Fibrilação Atrial/prevenção & controle , Métodos Epidemiológicos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeos Natriuréticos/sangue , Prognóstico , Prevenção Secundária , Tetrazóis/uso terapêutico , Troponina T/sangue , Valina/análogos & derivados , Valina/uso terapêutico , ValsartanaRESUMO
Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.
Assuntos
Teorema de Bayes , Metanálise como Assunto , Bioestatística , Proteína C-Reativa/genética , Proteína C-Reativa/metabolismo , Fibrinogênio/metabolismo , Marcadores Genéticos , Humanos , Modelos Estatísticos , Fenótipo , Polimorfismo de Nucleotídeo ÚnicoRESUMO
BACKGROUND: Atrial fibrillation (AF) is the most frequently occurring cardiac arrhythmia with often serious clinical consequences. Many patients have contraindications to anticoagulation, and it is often underused in clinical practice. The addition of clopidogrel to aspirin (ASA) has been shown to reduce vascular events in a number of high-risk populations. Irbesartan is an angiotensin receptor-blocking agent that reduces blood pressure and has other vascular protective effects. METHODS AND RESULTS: ACTIVE W is a noninferiority trial of clopidogrel plus ASA versus oral anticoagulation in patients with AF and at least 1 risk factor for stroke. ACTIVE A is a double-blind, placebo-controlled trial of clopidogrel in patients with AF and with at least 1 risk factor for stroke who receive ASA because they have a contraindication for oral anticoagulation or because they are unwilling to take an oral anticoagulant. ACTIVE I is a partial factorial, double-blind, placebo-controlled trial of irbesartan in patients participating in ACTIVE A or ACTIVE W. The primary outcomes of these studies are composites of vascular events. A total of 14000 patients will be enrolled in these trials. CONCLUSIONS: ACTIVE is the largest trial yet conducted in AF. Its results will lead to a new understanding of the role of combined antiplatelet therapy and the role of blood pressure lowering with an angiotensin II receptor blocker in patients with AF.
Assuntos
Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Compostos de Bifenilo/uso terapêutico , Inibidores da Agregação Plaquetária/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Projetos de Pesquisa , Tetrazóis/uso terapêutico , Ticlopidina/análogos & derivados , Idoso , Fibrilação Atrial/complicações , Clopidogrel , Método Duplo-Cego , Feminino , Humanos , Irbesartana , Masculino , Ticlopidina/uso terapêuticoRESUMO
AIMS: To present and discuss a comprehensive and ready to use prediction model of risk of death after myocardial infarction based on the very recently concluded follow-up of the large GISSI-Prevenzione cohort and on the integrated evaluation of different categories of risk factors: those that are non-modifiable, and those related to lifestyles, co-morbidity, background, and other conventional clinical complications produced by the index myocardial infarction. METHODS: The 11-324 men and women recruited in the study within 3 months from their index myocardial infarction have been followed-up to 4 years. The following risk factors have been used in a Cox proportional hazards model: non-modifiable risk factors: age and sex; complications after myocardial infarction: indicators of left ventricular dysfunction (signs or symptoms of acute left ventricular failure during hospitalization, ejection fraction, NYHA class and extent of ventricular asynergy at echocardiography), indicators of electrical instability (number of premature ventricular beats per hour, sustained or repetitive arrhythmias during 24-h Holter monitoring), indicators of residual ischaemia (spontaneous angina pectoris after myocardial infarction, Canadian Angina Classification class, and exercise testing results); cardiovascular risk factors: smoking habits, history of diabetes mellitus and arterial hypertension, systolic and diastolic blood pressure, blood total and HDL cholesterol, triglycerides, fibrinogen, leukocytes count, intermittent claudication, and heart rate. Multiple regression modelling was assessed by receiver operating characteristic (ROC) analysis. Generalizability of the models was assessed through cross validation and bootstrapping techniques. POPULATION AND RESULTS: During the 4 years of follow-up, a total of 1071 patients died. Age and left ventricular dysfunction were the most relevant predictors of death. Because of pharmacological treatments, total blood cholesterol, triglycerides, and blood pressure values were not significantly associated with prognosis. Sex-specific prediction equations were formulated to predict risk of death according to age, simple indicators of left ventricular dysfunction, electrical instability, and residual ischaemia along with the following cardiovascular risk factors: smoking habits, history of diabetes mellitus and arterial hypertension, blood HDL cholesterol, fibrinogen, leukocyte count, intermittent claudication, and heart rate. The predictive models produced on the basis of information available in the routine conditions of clinical care after myocardial infarction provide ready to use and highly discriminant criteria to guide secondary prevention strategies. CONCLUSIONS AND IMPLICATIONS: Besides documenting what should be the preferred and practicable focus of clinical attention for today's patients, the experience of GISSI-Prevenzione suggests that periodically and prospectively collected databases on naturalistic' cohorts could be an important option for updating and verifying the impact of guidelines, which should incorporate the different components of the complex profile of cardiovascular risk. The GISSI Prevenzione risk function is a simple tool to predict risk of death and to improve clinical management of subjects with recent myocardial infarction. The use of predictive risk algorithms can favour the shift from medical logic, based on the treatment of single risk factors, to one centred on the patient as a whole as well as the tailoring of medical interventions according to patients' overall risk.
Assuntos
Infarto do Miocárdio/mortalidade , Adulto , Fatores Etários , Idoso , Pressão Sanguínea/fisiologia , Colesterol/sangue , Feminino , Seguimentos , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Infarto do Miocárdio/complicações , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Fatores de Risco , Fatores Sexuais , Volume Sistólico/fisiologia , Análise de Sobrevida , Fatores de Tempo , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/diagnóstico , Talassemia beta/epidemiologiaAssuntos
Fibrinolíticos/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/uso terapêutico , Terapia Trombolítica/métodos , Quimioterapia Combinada , Humanos , Reperfusão Miocárdica , Ensaios Clínicos Controlados Aleatórios como Assunto , Proteínas Recombinantes/uso terapêutico , Ativador de Plasminogênio Tecidual/uso terapêuticoRESUMO
The investigation on the susceptibility genes of myocardial infarction has initiated substantially in the last 20 years. Most efforts have been mainly addressed to identify and evaluate genes involved in those systems already suspected to be implicated in the pathogenesis of coronary heart disease. Principal examples are lipid metabolism, coagulation and fibrinolytic systems, membrane receptors of platelets, levels of plasma homocysteine and vascular tone. Therefore up to now, the identification of the genetic factors of myocardial infarction has been carried out through case-control association studies employing a "candidate gene" approach. This method has often led to controversial results, usually difficult to compare. This is an attempt to provide a progress report on the principal susceptibility genes of coronary heart disease.
Assuntos
Predisposição Genética para Doença/genética , Infarto do Miocárdio/genética , Estudos de Casos e Controles , Hemostasia/genética , Homocisteína/genética , Homocisteína/metabolismo , Humanos , Metabolismo dos Lipídeos , Sistema Renina-Angiotensina/genéticaRESUMO
BACKGROUND: Atrial fibrillation is the most common supraventricular arrhythmia in patients with acute myocardial infarction. Recent advances in pharmacological treatment of myocardial infarction may have changed the impact of this arrhythmia. OBJECTIVE: To assess the incidence and prognosis of atrial fibrillation complicating myocardial infarction in a large population of patients receiving optimal treatment, including angiotensin converting enzyme (ACE) inhibitors. METHODS: Data were derived from the GISSI-3 trial, which included 17 944 patients within the first 24 hours after acute myocardial infarction. Atrial fibrillation was recorded during the hospital stay, and follow up visits were planned at six weeks and six months. Survival of the patients at four years was assessed through census offices. RESULTS: The incidence of in-hospital atrial fibrillation or flutter was 7.8%. Atrial fibrillation was associated with indicators of a worse prognosis (age > 70 years, female sex, higher Killip class, previous myocardial infarction, treated hypertension, high systolic blood pressure at entry, insulin dependent diabetes, signs or symptoms of heart failure) and with some adverse clinical events (reinfarction, sustained ventricular tachycardia, ventricular fibrillation). After adjustment for other prognostic factors, atrial fibrillation remained an independent predictor of increased in-hospital mortality: 12.6% v 5%, adjusted relative risk (RR) 1.98, 95% confidence interval (CI) 1.67 to 2.34. Data on long term mortality (four years after acute myocardial infarction) confirmed the persistent negative influence of atrial fibrillation (RR 1.78, 95% CI 1.60 to 1.99). CONCLUSIONS: Atrial fibrillation is an indicator of worse prognosis after acute myocardial infarction, both in the short term and in the long term, even in an unselected population.
Assuntos
Fibrilação Atrial/etiologia , Infarto do Miocárdio/complicações , Idoso , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/mortalidade , Feminino , Seguimentos , Mortalidade Hospitalar , Hospitalização , Humanos , Incidência , Itália/epidemiologia , Masculino , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Prognóstico , Recidiva , Análise de SobrevidaRESUMO
Coronary artery disease is a complex and multifactorial pathology. Although the environmental component of coronary artery disease has been thoroughly investigated and is hence well known, knowledge about the genetic factors implicated in this disease is still scarce. Technological advances and the fact that the Human Genome Project has almost been completed allow the application of approaches that were not feasible few years ago to the genetic investigation of complex diseases. The aim of the PROCARDIS study is to identify new susceptibility genes of precocious coronary artery disease, through a genome-wide screen applying statistical methods of linkage analysis followed by a family-based association study. The originality of PROCARDIS lies in the fact that it is an international multicenter study. This allows recruitment of a very large number of individuals so that the population size, considered up to now unachievable, is adequate for the aims of the study.
Assuntos
Ligação Genética , Predisposição Genética para Doença , Estudos Multicêntricos como Assunto , Infarto do Miocárdio/genética , Humanos , Seleção de Pacientes , Linhagem , Estatísticas não Paramétricas , Terminologia como AssuntoRESUMO
OBJECTIVE: To estimate the cost effectiveness of treatment with n-3 polyunsaturated fatty acids (PUFA) for secondary prevention after myocardial infarction (MI). DESIGN AND SETTING: The cost-effectiveness analysis of n-3 PUFA treatment after MI was based on morbidity and mortality data and the use of resources obtained prospectively during the 3.5 year follow-up period of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto (GISSI)-Prevenzione study. The cost-effectiveness analysis took into account the incremental number of life-years gained and the incremental costs for hospital admissions, diagnostic tests and drugs, applying a 5% discount rate. The value for money of n-3 PUFA treatment was assessed using the cost-effectiveness ratio and the number needed to treat (NNT) approach. PERSPECTIVE: Third-party payer. MAIN OUTCOME MEASURES AND RESULTS: The incremental cost-effectiveness ratio for n-3 PUFA in the basecase scenario was 24,603 euro (EUR, 1999 values) per life-year gained (95% confidence interval: 22,646 to 26,930). Sensitivity analysis included the analysis of extremes, producing estimates varying from EUR15,721 to EUR52,524 per life-year gained. 172 patients would need to be treated per year with n-3 PUFA, at an annual cost of EUR68,000, in order to save 1 patient. This is comparable with the NNT value, and associated annual cost for simvastatin, but less costly than that for pravastatin. CONCLUSIONS: The cost effectiveness of long term treatment with n-3 PUFA is comparable with other drugs recently introduced in the routine care of secondary prevention after MI. Since the clinical benefit provided by n-3 PUFA is additive, this therapy should be added to the established routine practice, with additive costs.
Assuntos
Análise Custo-Benefício , Farmacoeconomia , Ácidos Graxos Ômega-3/economia , Infarto do Miocárdio/economia , Ácidos Graxos Ômega-3/uso terapêutico , Humanos , Reembolso de Seguro de Saúde , Itália , Infarto do Miocárdio/prevenção & controle , Estudos ProspectivosRESUMO
OBJECTIVES: We sought to determine whether the clinical effects of early angiotensin-converting enzyme (ACE) inhibitor (ACEi) treatment for acute myocardial infarction (MI) are influenced by the concomitant use of aspirin (ASA). BACKGROUND: Aspirin and ACEi both reduce mortality when given early after MI. Aspirin inhibits the synthesis of vasodilating prostaglandins, and, in principle, this inhibition might antagonize some of the effects of ACEi. But it is uncertain whether, in practice, this influences the effects of ACEi on mortality and major morbidity after MI. METHODS: This overview sought individual patient data from all trials involving more than 1,000 patients randomly allocated to receive ACEi or control starting in the acute phase of MI (0-36 h from onset) and continuing for four to six weeks. Data on concomitant ASA use were available for 96,712 of 98,496 patients in four eligible trials (and for none of 1,556 patients in the one other eligible trial). RESULTS: Overall 30-day mortality was 7.1% among patients allocated to ACEi and 7.6% among those allocated to control, corresponding to a 7% (standard deviation [SD], 2%) proportional reduction (95% confidence interval 2% to 11%, p = 0.004). Angiotensin-converting enzyme inhibitor was associated with similar proportional reductions in 30-day mortality among the 86,484 patients who were taking ASA (6% [SD, 3%] reduction) and among the 10,228 patients who were not (10% [SD, 5%] reduction: chi-squared test of heterogeneity between these reductions = 0.4; p = 0.5). Angiotensin-converting enzyme inhibitor produced definite increases in the incidence of persistent hypotension (17.9% ACEi vs. 9.4% control) and of renal dysfunction (1.3% ACEi vs. 0.6% control), but there was no good evidence that these effects were different in the presence or absence of ASA (chi-squared for heterogeneity = 0.4 and 0.0, respectively; both not significant). Nor was there good evidence that the effects of ACEi on other clinical outcomes were changed by concomitant ASA use. CONCLUSIONS: Both ASA and ACEi are beneficial in acute MI. The present results support the early use of ACEi in acute MI, irrespective of whether or not ASA is being given.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aspirina/uso terapêutico , Inibidores de Ciclo-Oxigenase/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Idoso , Quimioterapia Combinada , Feminino , Humanos , Masculino , Infarto do Miocárdio/mortalidade , Fatores de TempoRESUMO
Aspirin (ASA) and angiotensin-converting enzyme inhibitor (ACEi) therapy reduce mortality when administered early after the onset of myocardial infarction. ASA can antagonize some effects of ACEi therapy by inhibiting the synthesis of vasodilating prostaglandins; however, the evidence for this effect from large controlled trials is contradictory. The authors analyzed a database of 18,895 patients of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardio-3 (GISSI-3) Trial in which patients were allocated either to receive lisinopril or not to receive lisinopril within 24 hours of the onset of symptoms of myocardial infarction. The aim of the study was to verify the possible negative interaction between ASA and the ACEi lisinopril in the postacute phase of acute myocardial infarction. Of 18,895 analyzable patients, 15,841 received ASA at entry. Overall lisinopril reduced 42-day mortality from 7.1% to 6.3%. In patients receiving ASA, mortality was reduced by lisinopril from 6.0% to 5.4%, and from 13.0% to 10.8% in patients not receiving ASA. The difference in proportional reductions of mortality corresponds to the fact that a more marked lisinopril effect is seen in patients at higher baseline risk across all study subgroups, one of which coincides with the no-ASA group. The analysis of the inhospital incidence of major clinical events did not reveal a potentially negative interaction between ASA and lisinopril. The same findings were obtained from the analysis of reinfarction at 42 days. The interaction between ASA and lisinopril was also tested by multivariate analysis adjusted for confounding variables at entry, and the interaction tests were not statistically significant. Serum creatinine levels at 42 days were significantly higher in lisinopril group than in the control group. Systolic and diastolic blood pressures in lisinopril group were significantly lower than controls at 42 days. The effect of lisinopril on creatinine and blood pressure did not differ between the ASA and no-ASA groups. ASA does not decrease the mortality benefit of early lisinopril after myocardial infarction, nor does it increase the risk of major adverse events. Lisinopril is safe and effective when given early after the onset of myocardial infarction, regardless of a concomitant administration of ASA started early and continued over a 6-week period.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aspirina/uso terapêutico , Lisinopril/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Idoso , Pressão Sanguínea/efeitos dos fármacos , Creatinina/sangue , Interações Medicamentosas , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/sangue , Infarto do Miocárdio/mortalidade , Razão de Chances , Análise de Regressão , Taxa de Sobrevida , Fatores de TempoAssuntos
Angina Instável/tratamento farmacológico , Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Terapia com Hirudina , Infarto do Miocárdio/tratamento farmacológico , Angina Instável/mortalidade , Doenças Cardiovasculares/mortalidade , Eletrocardiografia , Humanos , Estudos Multicêntricos como Assunto , Infarto do Miocárdio/mortalidade , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
The Coordinating Centre (CC) of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico (GISSI) used telecommunication technology to develop a computerized network system for the data management of the GISSI studies. Through a personal computer (PC), a communication program, a modem and a telephone line, the investigator in each participating centre can connect with a micro-computer at the CC, to recruit/randomize patients and download reports on the progress of the trial. In the first case, the investigator is required to answer a set of predefined questions, and thereby the system automatically checks eligibility criteria and randomly assigns the patient to a treatment arm. In the second case, once the investigator has made a choice from a list of standard reports and the relative query on CC central database, the generation, the formatting and the transfer of the selected report to the PC are executed automatically on line. The main advantages of this system are a reduction in number of mistakes in data completion and in the human and economic resources required, as well as the real time updating of participating centres. The system was successfully adopted in the GISSI-3 trial (200 Coronary Care Units and 19,394 patients enrolled), in the European arm of the CORE trial and it is currently being used in the GISSI-Prevenzione trial.
Assuntos
Ensaios Clínicos como Assunto/métodos , Redes de Comunicação de Computadores/organização & administração , Estudos Multicêntricos como Assunto/métodos , Telecomunicações , Algoritmos , Humanos , Internet , Itália , Distribuição Aleatória , Projetos de Pesquisa , SoftwareRESUMO
The Internet and World Wide Web have recently been introduced into the management of some aspects of large-scale clinical trials such as remote randomization and data entry and the distribution of information on trial progress. Electronic mail and websites have also been used to enhance communication among people involved in a clinical trial. The Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico acuto (GISSI) used telecommunications and the Internet in some recent large-scale clinical trials. GISSI constructed a website to keep the medical and cardiology community informed about the progress of its studies. Websites for clinical trials could play an important role in the future, especially in international clinical trials. The website could provide information such as study material and study news and tools such as electronic forums on protocol application for use by investigators around the world. This article describes the GISSI experience and outlines an appropriate structure for a clinical trial website.
Assuntos
Internet , Ensaios Clínicos Controlados Aleatórios como Assunto , Ensaios Clínicos como Assunto , Redes de Comunicação de Computadores , Previsões , Humanos , Serviços de Informação , Cooperação Internacional , Internet/tendências , Itália , Informática Médica , Estudos Multicêntricos como Assunto , Infarto do Miocárdio , Ensaios Clínicos Controlados Aleatórios como Assunto/classificação , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/tendências , TelecomunicaçõesRESUMO
BACKGROUND: The aim of this study was to evaluate the prognostic significance of the pressure-rate product (PRP) obtained during exercise stress testing and of its change from rest to maximal exercise (dPRP) in a population of survivors of acute myocardial infarction treated with thrombolytic agents. METHODS AND RESULTS: Survivors of acute myocardial infarction (n = 6251) from the GISSI-2 database, who underwent a maximal symptom-limited exercise test with either bicycle ergometer or treadmill, were followed up for 6 months. PRP and dPRP values were dichotomized (=21,700 and >21,700, =11, 600 and >11,600, respectively) and analyzed in a multivariate Cox model individually and simultaneously with other ergometric variables. Six-month mortality rate was 0.8% in the high PRP group and 2.0% in the low PRP group. Low PRP was an independent predictor of 6-month mortality rate (relative risk [RR] 1.97, 95% confidence interval [CI] 1.24 to 3.13). Patients with low dPRP had mortality rates higher than patients with high dPRP (2.1% vs 0.8%). At the multivariate analysis, low dPRP showed negative predictive value (RR 1.97, 95% CI 1.23 to 3.16). A further multivariate analysis was performed with PRP and dPRP, also adjusting for low work capacity, abnormal systolic blood pressure response to exercise, and symptomatic-induced ischemia. The results showed that low work capacity, low PRP, and symptomatic exercise-induced ischemia were still significantly associated with higher 6-month mortality rate (P =.04,.02, and.05; RR = 1.68, 1.71, and 1.78 respectively). CONCLUSIONS: PRP is a predictive index to assess prognosis in survivors of acute myocardial infarction treated with thrombolytic agents able to perform an exercise test after acute myocardial infarction, but its usefulness appears to be limited, considering that these patients were at low risk.
Assuntos
Pressão Sanguínea/fisiologia , Teste de Esforço , Fibrinolíticos/uso terapêutico , Frequência Cardíaca/fisiologia , Infarto do Miocárdio/tratamento farmacológico , Terapia Trombolítica , Idoso , Análise de Variância , Intervalos de Confiança , Ergometria , Feminino , Seguimentos , Previsões , Humanos , Masculino , Análise Multivariada , Infarto do Miocárdio/fisiopatologia , Isquemia Miocárdica/etiologia , Razão de Chances , Esforço Físico/fisiologia , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Descanso/fisiologia , Fatores de Risco , Taxa de Sobrevida , Avaliação da Capacidade de TrabalhoRESUMO
BACKGROUND: We conducted a 10-year follow-up of the 11 712 patients with acute myocardial infarction randomized in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto-1 study, the first large trial assessing thrombolytic therapy. METHODS AND RESULTS: Information on survival at 10 years was obtained for the 93% of all randomized patients through the census offices of their towns of residence. The difference in survival produced by streptokinase and sustained up to 1 year was still significant at 10 years (log-rank test, P=0.02), with the absolute benefit of 19 (95% CI 1 to 37) lives saved per 1000 patients treated. The time dependence of the extent of the benefit was confirmed, as the higher mortality rate reductions found in patients treated earlier were still present at 10 years. In the overall population, most of the benefit was obtained before hospital discharge (RR 0.81, 95% CI 0.72 to 0.90), since no difference in survival between thrombolyzed and control patients discharged alive was found at 10 years (RR 0.98, 95% CI 0.90 to 1.06). However, a slight albeit nonsignificant divergence of the survival curves of patients randomized within the first hour was observed [90 (95% CI 34 to 146) lives saved per 1000 at 10 years versus 72 (95% CI 37 to 107) lives saved at hospital discharge]. CONCLUSIONS: The benefits of a single intravenous infusion of 1.5 million units of streptokinase in prolonging survival of patients with acute myocardial infarction is sustained up to 10 years, with a still-evident trend in favor of the patients admitted earlier.
Assuntos
Infarto do Miocárdio/tratamento farmacológico , Estreptoquinase/uso terapêutico , Terapia Trombolítica , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Taxa de Sobrevida , Fatores de TempoRESUMO
BACKGROUND: A protective role of smoking in terms of mortality after acute myocardial infarction treated with thrombolytic agents was recently suggested, and this was attributed to the increased chance that smokers will achieve early complete perfusion after thrombolysis. The purpose of the present analysis of the GISSI-2 database was to evaluate the effect of smoking on in-hospital mortality, reinfarction and stroke rates. METHODS AND RESULTS: This analysis concerns 2611 (26.9%) nonsmokers, 1932 (19.9%) ex-smokers and 5151 (53.0%) active smokers with a first confirmed MI, treated with thrombolytic agents. The relationship between smoking habits and outcome was evaluated by unadjusted and adjusted analysis. Reinfarction and stroke rates were significantly lower in smokers (1.5 and 0.8% respectively) than in ex-smokers (2.5 and 1.1%) or nonsmokers (2.5% and 1.2%). In-hospital mortality significantly increased from 4.7% in smokers, to 7.6% in ex-smokers and 13.8% in nonsmokers. These differences may be due to the different characteristics of the three groups; in particular, smokers were younger than nonsmokers. After adjusted analysis, smoking was not confirmed to be a protective factor for reinfarction, stroke and mortality: OR 1.35 (95% Cl 0.91-2.02), 0.79 (95% Cl 0.58-1.06) and 0.80 (95% Cl 0.60-1.07) respectively. CONCLUSIONS: Active smokers presented a lower incidence of reinfarction, stroke and in-hospital mortality rates, but after adjustment for other clinical-epidemiological variables, the apparent protective role of smoking was not confirmed.