A multicenter, randomized study of argatroban versus heparin as adjunct to tissue plasminogen activator (TPA) in acute myocardial infarction: myocardial infarction with novastan and TPA (MINT) study.

OBJECTIVES: This study examined the effect of a small-molecule, direct thrombin inhibitor, argatroban, on reperfusion induced by tissue plasminogen activator (TPA) in patients with acute myocardial infarction (AMI). BACKGROUND: Thrombin plays a crucial role in thrombosis and thrombolysis. In vitro and in vivo studies have shown that argatroban has advantages over heparin for the inhibition of clot-bound thrombin and for the enhancement of thrombolysis with TPA. METHODS: One hundred and twenty-five patients with AMI within 6 h were randomized to heparin, low-dose argatroban or high-dose argatroban in addition to TPA. The primary end point was the rate of thrombolysis in myocardial infarction (TIMI) grade 3 flow at 90 min. RESULTS: TIMI grade 3 flow was achieved in 42.1% of heparin, 56.8% of low-dose argatroban (p = 0.20 vs. heparin) and 58.7% of high-dose argatroban patients (p = 0.13 vs. heparin). In patients presenting after 3 h, TIMI grade 3 flow was significantly more frequent in high-dose argatroban versus heparin patients: 57.1% versus 20.0% (p = 0.03 vs. heparin). Major bleeding was observed in 10.0% of heparin, and in 2.6% and 4.3% of low-dose and high-dose argatroban patients, respectively. The composite of death, recurrent myocardial infarction, cardiogenic shock or congestive heart failure, revascularization and recurrent ischemia at 30 days occurred in 37.5% of heparin, 32.0% of low-dose argatroban and 25.5% of high-dose argatroban patients (p = 0.23). CONCLUSIONS: Argatroban, as compared with heparin, appears to enhance reperfusion with TPA in patients with AMI, particularly in those patients with delayed presentation. The incidences of major bleeding and adverse clinical outcome were lower in the patients receiving argatroban.

[Bedside cardiac catheterization. Advantages and disadvantages]. / Cateterismo cardíaco à beira do leito. Vantagens e desvantagens.

Three hundred patients submitted to bedside heart catheterization (BHC) from 1973 to 1985 were studied, in order to assess advantages and risks of the procedure. Two-hundred and sixty seven patients (89%) suffered a myocardial infarction (MI) and 146 of them were in functional class (Killip) II, 36 in FC III and 71 in FC IV. Thirty cases were submitted to BHC due to congestive heart failure. BHC was successful in 288 patients (96%) and the wedge pressure (WP) could be measured in 236 cases (78.7%). The WP was less than 18 mmHg in 47.2% of the patients in FC II, in 44.9% of the patients in FC III and in 35.3% of those in FC IV. Minor complications occurred in 33 cases (11.0%); balloon rupture in 12 (4.0%), transient arrhythmias in 11 (3.7%) and lumen obstruction in another 10 cases (3.3%). Forty five patients (15.0%) presented major complications related to the procedure: pulmonary infarction (PI) in 18 cases (6%), phlebitis in 15 cases (5%), sustained arrhythmias in 10 cases (3.3%), pulmonary artery rupture and endocarditis each in 1 case. The mean age between the group of patients with and without complications was similar the maintenance time as greater in the group of patients with complications: 3.4 +/- 0.2 vs 2.7 +/- 0.1 days (p less than 0.05). We concluded that many patients with clinical evidence of heart failure had WP smaller than 18 mmHg, emphasizing the value of the procedure in patients with complicated MI. The maintenance time was associated with the occurrence of complications, mainly PI and phlebitis.

[Changes in the ST segment in unstable angina pectoris. Its prognostic value]. / Alteraciones del segmento ST en la angina pectoris inestable. Su valor pronóstico.

Out of 145 patients with unstable angina hospitalized at CCU of the Instituto de Cardiologia do Rio Grande do Sul (Brazil) in 1981, 69 were studied: group I = 23 case (33.3%) with transient ST segment depression, group II = 13 cases (18.8%) with transient ST segment elevation, group III (control) = 33 cases (47.8%) without acute EKG changes. Group I showed a higher incidence of double-triple coronary artery involvement: 71.4% VS 53.8 and 63.3% respectively (non significant). This group also showed a higher number of patients with severe angina and who suffered acute myocardial infarction during follow-up, although without statistical significance. There were 8 deaths (34.8%) in group I, 3 (23.1%) in group II and 4 (12.1%) in group III (chi 2 = 4.11, p greater than 0.05). The 36 months survival rate was lower in group I than in groups II and III: 52.9% VS. 75.2% (NS) and 89.7% (P less than 0.02) respectively. We conclude that acute EKG changes, mainly transient ST segment depression, in unstable angina, are markers of high risk patients.