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1.
Eur J Radiol ; 114: 6-13, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31005178

RESUMO

BACKGROUND: This study was designed to investigate the agreement of 2D transthoracic echocardiography (2D TTE) with cardiovascular magnetic resonance imaging (CMR) in a contemporary population of ST-elevation myocardial infarction (STEMI) patients. METHODS: In this subanalysis of the GIPS-III trial, a randomized controlled trial investigating the administration of metformin in STEMI patients to prevent reperfusion injury, we studied 259 patients who underwent same-day CMR and 2D TTE assessments four months after hospitalization for a first STEMI. Bland-Altman analyses were performed to assess agreement between LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF), and LV mass measurements. Sensitivity and specificity of 2D TTE to detect categories of LVEF (≤35%, 35-50%, ≥50%) was determined. Linear regression of absolute differences in measurements between imaging modalities was used to investigate whether patient characteristics impact measurement bias. RESULTS: Pairwise difference (bias) and 95% limits of agreement between CMR and 2D TTE measurements were +84 (37, 147) ml for LVEDV, +39 (6, 85) ml for LVESV, -1.1 ± 13.5% for LVEF, and -75 (-154, -14) g for LV mass. Sensitivity and specificity of 2D TTE to detect subjects with moderately depressed LVEF (35-50%) as measured by CMR were 52% and 88% respectively. We observed a significant effect of enzymatic infarct size on bias between 2D TTE and CMR in measuring LVESV and LVEF (P = 0.029, P = 0.001 respectively), of age and sex on bias between 2D TTE and CMR in measuring LV mass (P = 0.027, P < 0.001) and LVEDV (P = 0.001, P = 0.039), and of heart rate on bias between 2D TTE and CMR in LV volume measurements (P = 0.004, P = 0.016). CONCLUSIONS: Wide limits of agreement, underestimation of LV volumes and overestimation of LV mass was observed when comparing 2D TTE to CMR. Enzymatic infarct size, age, sex, and heart rate are potential sources of bias between imaging modalities.


Assuntos
Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Fármacos Cardiovasculares/administração & dosagem , Esquema de Medicação , Ecocardiografia/métodos , Feminino , Ventrículos do Coração/diagnóstico por imagem , Humanos , Angiografia por Ressonância Magnética/métodos , Masculino , Metformina/administração & dosagem , Pessoa de Meia-Idade , Imagem Multimodal/métodos , Traumatismo por Reperfusão Miocárdica/diagnóstico , Traumatismo por Reperfusão Miocárdica/prevenção & controle , Reprodutibilidade dos Testes , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Sensibilidade e Especificidade , Disfunção Ventricular Esquerda/diagnóstico
2.
Medicine (Baltimore) ; 98(17): e15277, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31027084

RESUMO

There exists controversy on whether and for how long anticoagulation is necessary after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).We aimed to study the impact of prolonged (>24 h) or brief (<24 h) postprocedural anticoagulation on infarct size assessed by cardiac magnetic resonance (CMR) after 30 days as well as on left ventricular ejection fraction (LVEF) and left ventricular (LV) remodeling evaluated by 2D-echocardiography after 9 months from the INNOVATION trial (Clinical Trial Registration: NCT02324348).Of the 114 patients (mean age: 59.5 years) enrolled, 76 (66.7%) received prolonged anticoagulation therapy (median duration: 72.6 h) and 38 (33.3%) patients received brief anticoagulation therapy (median duration: 5 h) after primary PCI. There was no significant difference in infarct size (mean size: 15.6% after prolonged anticoagulation versus 19.8% after brief anticoagulation, P = .100) and the incidence of microvascular obstruction (50.7% versus 52.9%, P = .830) between the groups. Even after adjusting, prolonged anticoagulation therapy could not reduce larger infarct (defined as >75 percentile of infarct size; 19.7% versus 35.3%; adjusted odd ratio [OR]: 0.435; 95% confidence interval [CI]: 0.120-1.57; P = .204). Similar results were observed in subanalyses of major high-risk subgroups. Moreover, follow-up LVEF <35% (3.2% versus 7.4%; adjusted OR: 0.383; 95% CI: 0.051-2.884; P = .352) and LV remodeling (defined as >20% increase in LV end-diastolic volume; 37.1% versus 18.5%; adjusted OR: 2.249; 95% CI: 0.593-8.535; P = .234) were similar between groups.These data suggest that prolonged postprocedural anticoagulation may not provide much benefit after successful primary PCI in patients with STEMI. However, further studies are needed.


Assuntos
Anticoagulantes/uso terapêutico , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Idoso , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Volume Sistólico/efeitos dos fármacos , Fatores de Tempo , Remodelação Ventricular/efeitos dos fármacos
3.
J Biol Regul Homeost Agents ; 33(2): 485-490, 2019 Mar-Apr,.
Artigo em Inglês | MEDLINE | ID: mdl-30892000

RESUMO

Acute ST-segment elevation myocardial infarction (STEMI) is one of the most common cardiovascular emergencies. With the improvement of living standards, the incidence and mortality rate of STEMI has shown a significant growth trend.


Assuntos
Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Ticagrelor/uso terapêutico , Humanos , Resultado do Tratamento
4.
Anatol J Cardiol ; 21(3): 163-171, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30821716

RESUMO

OBJECTIVE: Currently, there is still no effective strategy to diminish the infarct size (IS) in patients with ST-segment elevation myocardial infarction (STEMI). According to a previous animal study, nicorandil treatment is a promising pharmaceutical treatment to limit the infarct area. In this study, we aim to investigate the effects of continual nicorandil administration on the IS and the clinical outcomes in patients with STEMI who underwent primary percutaneous coronary intervention (pPCI). METHODS: One hundred seventeen patients with STEMI and undergoing pPCI were randomly divided into the sustained nicorandil group (5 mg, three times daily) or the control group (only single nicorandil before PCI). The primary endpoint was the IS, evaluated by single-photon emission computed tomography (SPECT) 3 months after pPCI. RESULTS: Eighty-five patients completed the IS assessment via SPECT, and 99 participants were available for follow-up after 6 months. Finally, there was a statistical difference in the IS between the nicorandil and control groups {13% [interquartile range (IQR), 8-17] versus 16% [IQR, 12-20.3], p=0.027}. Additionally, we observed that maintained nicorandil administration significantly improved the left ventricular ejection fraction at 3 months and enhanced the activity tolerance (physical limitation and angina stability) at 6 months after PCI. CONCLUSION: Sustained nicorandil treatment reduced the IS and improved the clinical outcomes compared to the single nicorandil administration for patients with STEMI undergoing the pPCI procedure. Continuous cardioprotective therapy may be more beneficial for patients with STEMI.


Assuntos
Nicorandil/uso terapêutico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Vasodilatadores/uso terapêutico , Administração Oral , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nicorandil/administração & dosagem , Intervenção Coronária Percutânea , Estudos Prospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Resultado do Tratamento , Vasodilatadores/administração & dosagem
5.
Heart Lung Circ ; 28(5): 697-706, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30745015

RESUMO

BACKGROUND: Traditionally, opioids have been the analgesia of choice for patients with ST-Elevation Myocardial Infarction (STEMI). Recent studies, however, have raised the possibility of harmful effects of opioid administration through delayed onset of antiplatelet agents. OBJECTIVE: To perform a systematic review of the effects of parenteral opioids in patients presenting with STEMI. METHODS: Medical databases were systematically searched to 28 February 2018. Randomised control trials (RCTs) and observational studies were included if they interrogated the effects of parenteral opioids as compared to no opioid administration in STEMI patients. Outcomes included in-hospital, 30-day, one-year major adverse cardiac events (MACE) and platelet reactivity measures. The studies were evaluated using GRADE (Grade of Recommendation, Assessment, Development and Evaluation). RESULTS: One (1) RCT and 17 non-randomised, non-controlled observational studies were identified. The only RCT was of high quality, but only evaluated the pharmacokinetics of STEMI patients and had a small sample size. The remaining studies were of low-moderate quality, mainly due to eligibility criteria and confounding. Most studies report higher platelet reactivity with opioids, but clinical outcomes (MACE) were equivocal. CONCLUSION: This systematic review highlights the paucity of quality research evaluating the effect of opioids on its clinical and pharmacological effect on STEMI patients. Current literature indicates that opioids are associated with prolonged platelet reactivity. Whether this affects clinical outcomes remains to be established. Given the widespread use of opioids in STEMI, there is an urgent need for adequately powered trials investigating their safety.


Assuntos
Analgesia/métodos , Analgésicos Opioides/farmacologia , Manejo da Dor/métodos , Inibidores da Agregação de Plaquetas/farmacologia , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Interações de Medicamentos , Quimioterapia Combinada , Humanos , Medição da Dor
6.
Clin Drug Investig ; 39(3): 275-283, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30623372

RESUMO

BACKGROUND AND OBJECTIVE: Dual antiplatelet therapy is one of the main treatments in acute coronary syndrome (ACS). Switching antiplatelet agents may be necessary in some patients to improve efficacy or safety. The objective of this study was to determine the prevalence, predictors, and implications of clinical switching in patients during hospital admission and 1-year follow-up at discharge. METHODS: Observational, prospective, multicenter registry study in patients discharged following an admission for ACS and followed up for 1 year. We analyzed ischemic and bleeding events as well as treatment changes. RESULTS: We recruited 1717 patients; in-hospital switching occurred in 425 (24.8%): 15.1% to clopidogrel and 84.9% to newer antiplatelet drugs (prasugrel or ticagrelor). Those switched to newer antiplatelets were younger, with lower scores on the GRACE and CRUSADE scales, admitted more frequently for ST-elevation myocardial infarction and underwent more invasive management and percutaneous revascularization. The clinical cardiologist was responsible for most in-hospital switching to newer antiplatelets (79.6%). The loading dose of the second antiplatelet did not affect incidence of bleeding events. Post-discharge switching was infrequent (2%) and depended mainly on clinical indications; only 30% was related to a new ACS. CONCLUSIONS: In a contemporary registry with ACS, in-hospital switching of antiplatelet drugs was frequent. Those switched to newer antiplatelets were younger and admitted more frequently for ST-elevation myocardial infarction. Post-discharge switching was infrequent.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Clopidogrel/administração & dosagem , Cloridrato de Prasugrel/administração & dosagem , Ticagrelor/administração & dosagem , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia/epidemiologia , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/administração & dosagem , Prevalência , Prognóstico , Estudos Prospectivos , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Sistema de Registros , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico
7.
JAMA ; 321(1): 56-68, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30620371

RESUMO

Importance: Microvascular obstruction commonly affects patients with acute ST-segment elevation myocardial infarction (STEMI) and is associated with adverse outcomes. Objective: To determine whether a therapeutic strategy involving low-dose intracoronary fibrinolytic therapy with alteplase infused early after coronary reperfusion will reduce microvascular obstruction. Design, Setting, and Participants: Between March 17, 2016, and December 21, 2017, 440 patients presenting at 11 hospitals in the United Kingdom within 6 hours of STEMI due to a proximal-mid-vessel occlusion of a major coronary artery were randomized in a 1:1:1 dose-ranging trial design. Patient follow-up to 3 months was completed on April 12, 2018. Interventions: Participants were randomly assigned to treatment with placebo (n = 151), alteplase 10 mg (n = 144), or alteplase 20 mg (n = 145) by manual infusion over 5 to 10 minutes. The intervention was scheduled to occur early during the primary PCI procedure, after reperfusion of the infarct-related coronary artery and before stent implant. Main Outcomes and Measures: The primary outcome was the amount of microvascular obstruction (% left ventricular mass) demonstrated by contrast-enhanced cardiac magnetic resonance imaging (MRI) conducted from days 2 through 7 after enrollment. The primary comparison was the alteplase 20-mg group vs the placebo group; if not significant, the alteplase 10-mg group vs the placebo group was considered a secondary analysis. Results: Recruitment stopped on December 21, 2017, because conditional power for the primary outcome based on a prespecified analysis of the first 267 randomized participants was less than 30% in both treatment groups (futility criterion). Among the 440 patients randomized (mean age, 60.5 years; 15% women), the primary end point was achieved in 396 patients (90%), 17 (3.9%) withdrew, and all others were followed up to 3 months. In the primary analysis, the mean microvascular obstruction did not differ between the 20-mg alteplase and placebo groups (3.5% vs 2.3%; estimated difference, 1.16%; 95% CI, -0.08% to 2.41%; P = .32) nor in the analysis of 10-mg alteplase vs placebo groups (2.6% vs 2.3%; estimated difference, 0.29%; 95% CI, -0.76% to 1.35%; P = .74). Major adverse cardiac events (cardiac death, nonfatal MI, unplanned hospitalization for heart failure) occurred in 15 patients (10.1%) in the placebo group, 18 (12.9%) in the 10-mg alteplase group, and 12 (8.2%) in the 20-mg alteplase group. Conclusions and Relevance: Among patients with acute STEMI presenting within 6 hours of symptoms, adjunctive low-dose intracoronary alteplase given during the primary percutaneous intervention did not reduce microvascular obstruction. The study findings do not support this treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT02257294.


Assuntos
Oclusão Coronária/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Área Sob a Curva , Cateteres Cardíacos , Terapia Combinada , Angiografia Coronária , Oclusão Coronária/cirurgia , Vasos Coronários , Relação Dose-Resposta a Droga , Feminino , Humanos , Infusões Intra-Arteriais , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Qualidade de Vida , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Ativador de Plasminogênio Tecidual/efeitos adversos , Falha de Tratamento , Troponina T/sangue
8.
Int J Cardiol ; 274: 35-39, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-30236502

RESUMO

BACKGROUND: Tirofiban is recommended as bail out therapy in patients with ST-elevation myocardial infarction (STEMI). However, evidence regarding safety and efficacy of tirofiban is unclear. Tirofiban has been shown to improve ST-resolution, to decrease infarct size (IS) and to reduce incidence of major adverse cardiac and cerebrovascular events (MACCE). However, bleeding is enhanced in tirofiban treated patients. In this study, we aim to investigate efficacy and safety of Tirofiban in STEMI-patients. METHODS: 610 STEMI patients were analyzed. MACCE (death, myocardial infarction [MI], stroke) and TIMI bleeding events were registered during hospital course and 12 month follow-up. RESULTS: Tirofiban patients were slightly younger (tirofiban 63 ±â€¯13 years vs. control 65 ±â€¯14 years; p = 0.04). They had higher peak-high-sensitive troponin T [Hs-TnT] (tirofiban 6561 ±â€¯11,065 vs. control 4594 ±â€¯11,200, p-value = 0.047) and peak-creatine kinase [CK] (tirofiban 2742 ±â€¯5097 vs. control 1416 ±â€¯2160, p-value < 0.0001). Percutaneous coronary intervention (PCI) was more complex in tirofiban treated patients as radiation time (tirofiban 18 ±â€¯15 vs. control 14 ±â€¯13; p-value = 0.02) and use of contrast agent (tirofiban 240 ±â€¯106 vs. control 209 ±â€¯99; p-value = 0.01) was higher in tirofiban patients. However, there were no differences in MACCE (HR 0.877, 95% CI 0.62-1.25, p = 0.47) and bleeding (major: HR 1.494, 95% CI 0.65-3.44, p = 0.34; minor: HR 1.294, 95% CI 0.67-2.52, p = 0.45). CONCLUSION: MACCE and bleeding events were similar. However, PCI was more complex and infarcts larger in tirofiban treated patients.


Assuntos
Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Tirofibana/administração & dosagem , Idoso , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Alemanha/epidemiologia , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Fatores de Tempo , Tirofibana/efeitos adversos , Resultado do Tratamento
9.
Medicine (Baltimore) ; 97(45): e13010, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30407292

RESUMO

OBJECTIVE: Both Aspirin and Clopidogrel are considered as effective drugs in decreasing ischemic events, which potentially contribute to a promising application regarding the cardiovascular events. In the present study, we evaluated the efficacy of the combination of both Clopidogrel and Aspirin to determine the influence among inflammatory factors, cardiac function, and treatment outcome of patients suffering from ST-segment elevation myocardial infarction (STEMI) in the Hebei province of China. METHODS: To compare the efficacy of this combination therapy with a single Aspirin treatment, we experimented in 68 patients with the administration of both Clopidogrel and Aspirin as well as another 68 patients administered only with Aspirin. An enzyme-linked immunosorbent assay was used to measure the expression of inflammatory factors, thereby evaluating the effect on inflammation. In addition, a series of indexes related to cardiac function and renal function were monitored by use of a color Doppler ultrasound and an automatic biochemical analyzer, respectively. Myocardial injury-related indicators were detected. A multivariate logistic regression analysis was performed so we could identify potential risk factors. In addition, both postoperative hemorrhages and cardiac events were observed to evaluate the treatment outcome of patients with STEMI. RESULTS: Initially, the treatment outcome revealed a better efficacy in patients treated with the combination of both Clopidogrel and Aspirin, with the patients also showing more obviously alleviated myocardial injury, better cardiac and renal functions with lower serum levels of inflammatory factors. The lower incidence of postinfarction angina, recurrent myocardial infarction, stroke, and death also provide evidence that patients showed a better outcome after treatment with both Clopidogrel and Aspirin. CONCLUSION: Taken together, the combination therapy of Clopidogrel and Aspirin provided a better improvement on both the cardiac function and outcome of STEMI patients in the Hebei province of China, with reduced inflammation as well.


Assuntos
Aspirina/administração & dosagem , Inibidores da Agregação de Plaquetas/administração & dosagem , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Ticlopidina/análogos & derivados , Idoso , Clopidogrel , Citocinas/sangue , Quimioterapia Combinada , Feminino , Coração/efeitos dos fármacos , Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Ticlopidina/administração & dosagem , Resultado do Tratamento
10.
Medicine (Baltimore) ; 97(39): e12225, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30278492

RESUMO

Statin nonadherence or discontinuation is associated with increased cardiovascular events. Many factors related to the physicians or the patients are influential in this. We aimed to compare the compliance with statin therapy between the patients who first presented with ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina pectoris (UA) based on the target achievement according to the current dyslipidemia guidelines.We retrospectively acquired all the information about demographic characteristics, in-hospital revascularization procedures, prescribed treatments, and index and up to 6-month follow-up laboratory results of the first acute coronary syndrome patients. Acute coronary syndrome patients were divided into 3 groups as STEMI, NSTEMI, and UA.The STEMI group consisted of 260 patients, NSTEMI group consisted of 560 patients, and UA group consisted of 206 patients. Seventy-six percent of patients underwent percutaneous coronary interventions, 18.3% were managed medically, and 5.7% were referred for coronary artery bypass grafting. There was a significant decrease in low-density lipoprotein-cholesterol (LDL-C) values with the statin treatment at the follow-up in all 3 groups (for all P < .001). In the STEMI group, the percentage of those achieving the target LDL-C level was significantly higher than those who did not achieve the target according to both The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology dyslipidemia guidelines. The LDL-C target achievement rates were also higher in the STEMI group than in the NSTEMI and UA groups.Our study concluded that statin treatment goals were more attained in STEMI patients than NSTEMI and UA. All physicians should encourage lifelong intensive statin treatment in UA and NSTEMI patients such as STEMI patients.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Lipídeos/sangue , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Resultado do Tratamento
11.
Expert Opin Pharmacother ; 19(13): 1441-1450, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30185087

RESUMO

INTRODUCTION: Together with antiplatelet therapy, anticoagulants are vital to improve outcomes in patients presenting with ST-segment elevation myocardial infarction. Challenges lie in finding the optimal balance between the risk of bleeding and preventing thrombotic complications such as reinfarction or stent thrombosis. During the last decade, bivalirudin was introduced as a valid alternative to heparin for patients undergoing primary percutaneous coronary intervention. Several trials have been conducted to identify the agent with the best antithrombotic results at the lowest bleeding complication rate. In a rapidly evolving field with changes in vascular access, available P2Y12 inhibitors, and indications for glycoprotein IIb/IIIa inhibitor administration, conflicting evidence became available. Areas covered: This paper mainly focuses on the evidence above and gives brief discussion to the recent literature on anticoagulation in fibrinolytic therapy and advances in antiplatelet therapy. Expert opinion: To date, no robust evidence is available challenging unfractionated heparin as the primary choice for anticoagulation in patients presenting with ST-segment elevation myocardial infarction. Further research should include efforts to refine anticoagulation strategies on an individual patient level. For patients undergoing primary percutaneous coronary intervention, bivalirudin could be used as an alternative to unfractionated heparin, while enoxaparin or fondaparinux is an alternative agent for patients treated with fibrinolytic therapy.


Assuntos
Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Hemorragia/induzido quimicamente , Hirudinas , Humanos , Fragmentos de Peptídeos/uso terapêutico , Intervenção Coronária Percutânea/métodos , Proteínas Recombinantes/uso terapêutico , Terapia Trombolítica/métodos , Trombose/prevenção & controle , Resultado do Tratamento
12.
Clin Cardiol ; 41(8): 1004-1008, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30033595

RESUMO

There is clear association between the intensity of the acute inflammatory response during acute myocardial infarction (AMI) and adverse prognosis after AMI. Interleukin-1 (IL-1) is a pro-inflammatory cytokine released during AMI and involved in adverse remodeling and heart failure (HF). We describe a study to evaluate the safety and efficacy of IL-1 blockade using an IL-1 receptor antagonist (anakinra) during the acute phase of ST-segment elevation myocardial infarction (STEMI). The Virginia Commonwealth University-Anakinra Remodeling Trial-3 (VCU-ART3; http://www.ClinicalTrials.gov NCT01950299) is a phase 2, multicenter, double-blinded, randomized, placebo-controlled clinical trial comparing anakinra 100 mg once or twice daily vs matching placebo (1:1:1) for 14 days in 99 patients with STEMI. Patients who present to the hospital with STEMI within 12 hours of symptom onset will be eligible for enrollment. Patients will be excluded for a history of HF (functional class III-IV), severe valvular disease, severe kidney disease (stage 4-5), active infection, recent use of immunosuppressive drugs, active malignancy, or chronic autoimmune/auto-inflammatory diseases. We will measure the difference in the area under the curve for C-reactive protein between admission and day 14, separately comparing each of the anakinra groups with the placebo group. The P value will be considered significant if <0.025 to adjust for multiple comparisons. Patients will also be followed for up to 12 months from enrollment to evaluate cardiac remodeling (echocardiography), cardiac function (echocardiography), and major adverse cardiovascular outcomes (cardiovascular death, MI, revascularization, and new onset of HF).


Assuntos
Proteína C-Reativa/metabolismo , Insuficiência Cardíaca/prevenção & controle , Proteína Antagonista do Receptor de Interleucina 1/administração & dosagem , Interleucina-1/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Remodelação Ventricular/efeitos dos fármacos , Antirreumáticos/administração & dosagem , Antirreumáticos/uso terapêutico , Relação Dose-Resposta a Droga , Método Duplo-Cego , Ecocardiografia , Eletrocardiografia , Feminino , Seguimentos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
13.
Indian Heart J ; 70(3): 446-449, 2018 May - Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29961467

RESUMO

Primary percutaneous coronary intervention is the current standard of care in ST elevation myocardial infarction (STEMI). However, large thrombus is an independent predictor for stent thrombosis and major adverse cardiac events in patients undergoing primary angioplasty for STEMI. Here we report a series of STEMI patients with large thrombus burden treated successfully with low dose intracoronary thrombolysis. There was prompt and early ST resolution. There was improvement in thrombolysis in myocardial infarction (TIMI) flow and myocardial blush grade postlysis in all patients. Majority had recanalised infarct related coronary artery thus obviating the need for stenting. There was no inhospital or 1 month mortality or bleeding events. Hence intracoronary thrombolysis is an option in patients with large thrombus burden.


Assuntos
Trombose Coronária/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Adulto , Cateterismo Cardíaco , Angiografia Coronária , Trombose Coronária/diagnóstico , Trombose Coronária/tratamento farmacológico , Vasos Coronários , Relação Dose-Resposta a Droga , Eletrocardiografia , Feminino , Humanos , Infusões Intra-Arteriais , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Índice de Gravidade de Doença , Tenecteplase , Resultado do Tratamento
14.
Medicine (Baltimore) ; 97(26): e11206, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29952973

RESUMO

RATIONALE: Ticagrelor, a new type of P2Y12 receptor antagonist, has been highly recommended to be used in acute coronary syndrome by the latest guideline, but its side effects are not well-known. We seek to illustrate a potential fatal condition, thrombotic thrombocytopenic purpura (TTP), caused by ticagrelor. PATIENT CONCERNS: An 87-year-old man who had been prescribed with ticagrelor for 2 months after ST-elevation myocardial infarction (STEMI), presented with severe thrombocytopenia, anemia, renal and liver dysfunction, heart failure and fever. DIAGNOSES: Peripheral blood smear showed schistocytosis, and a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13) activity is low, with normal initial coagulation tests, which were compatible with a diagnosis of TTP. INTERVENTIONS: After cessation of ticagrelor and initiation of therapeutic plasma exchange, our patient recovered. OUTCOMES: Re-administration of ticagrelor aggravated TTP and led the patient to death. LESSONS: Clinicians should be aware of the possibility of ticagrelor-induced TTP in patients with a history of recent myocardial infarction; It is of crucial significance to discontinue and never reuse ticagrelor as long as it is suspected to be implicated in TTP.


Assuntos
Adenosina/análogos & derivados , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Púrpura Trombocitopênica Trombótica/induzido quimicamente , Proteína ADAMTS13/metabolismo , Adenosina/efeitos adversos , Idoso de 80 Anos ou mais , Evolução Fatal , Humanos , Masculino , Troca Plasmática/métodos , Púrpura Trombocitopênica Trombótica/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Ticagrelor , Suspensão de Tratamento
15.
Dtsch Med Wochenschr ; 143(11): 797-801, 2018 06.
Artigo em Alemão | MEDLINE | ID: mdl-29807379

RESUMO

Clinical management of patients with ST-elevation myocardial infarction (STEMI) is an emergency situation. Primary aim is urgent reestablishment of reperfusion by means of percutaneous coronary intervention (PCI). The European society of cardiology recently published the latest version of the guideline for management of patients with STEMI. A clear recommendation now exists for radial approach as access side for PCI as well as an intervention including the implantation of a drug eluting stent (DES). In patients with STEMI and multi vessel disease a complete revascularization should be planned on an individual basis either as part of the index procedure or as staged procedure. Heparin remains the routinely used anticoagulant and it remains unchanged that dual antiplatelet therapy is recommended after STEMI - duration of DAPT should be planned according to individual ischemic and bleeding risk.


Assuntos
Infarto do Miocárdio com Supradesnível do Segmento ST , Anticoagulantes/uso terapêutico , Cardiologia/organização & administração , Humanos , Intervenção Coronária Percutânea , Guias de Prática Clínica como Assunto , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia
16.
Chin Med J (Engl) ; 131(11): 1282-1288, 2018 Jun 05.
Artigo em Inglês | MEDLINE | ID: mdl-29786039

RESUMO

Background: Serum soluble ST2 (sST2) levels are elevated early after acute myocardial infarction and are related to adverse left ventricular (LV) remodeling and cardiovascular outcomes in ST-segment elevation myocardial infarction (STEMI). Beta-blockers (BB) have been shown to improve LV remodeling and survival. However, the relationship between sST2, final therapeutic BB dose, and cardiovascular outcomes in STEMI patients remains unknown. Methods: A total of 186 STEMI patients were enrolled at the Wuhan Asia Heart Hospital between January 2015 and June 2015. All patients received standard treatment and were followed up for 1 year. Serum sST2 was measured at baseline. Patients were divided into four groups according to their baseline sST2 values (high >56 ng/ml vs. low ≤56 ng/ml) and final therapeutic BB dose (high ≥47.5 mg/d vs. low <47.5 mg/d). Cox regression analyses were performed to determine whether sST2 and BB were independent risk factors for cardiovascular events in STEMI. Results: Baseline sST2 levels were positively correlated with heart rate (r = 0.327, P = 0.002), Killip class (r = 0.408, P = 0.000), lg N-terminal prohormone B-type natriuretic peptide (r = 0.467, P = 0.000), lg troponin I (r = 0.331, P = 0.000), and lg C-reactive protein (r = 0.307, P = 0.000) and negatively correlated to systolic blood pressure (r = -0.243, P = 0.009) and LV ejection fraction (r = -0.402, P = 0.000). Patients with higher baseline sST2 concentrations who were not titrated to high-dose BB therapy (P < 0.0001) had worse outcomes. Baseline high sST2 (hazard ratio [HR]: 2.653; 95% confidence interval [CI]: 1.201-8.929; P = 0.041) and final low BB dosage (HR: 1.904; 95% CI, 1.084-3.053; P = 0.035) were independent predictors of cardiovascular events in STEMI. Conclusions: High baseline sST2 levels and final low BB dosage predicted cardiovascular events in STEMI. Hence, sST2 may be a useful biomarker in cardiac pathophysiology.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas Adrenérgicos beta/uso terapêutico , Biomarcadores/sangue , Proteína 1 Semelhante a Receptor de Interleucina-1/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/patologia
17.
Med Sci Monit ; 24: 2767-2776, 2018 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-29726480

RESUMO

BACKGROUND This study aimed to investigate intracoronary nicorandil treatment on the no-reflow phenomenon (NRP) during primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) and to compare nicorandil with sodium nitroprusside. MATERIAL AND METHODS Patients with sustained acute STEMI who underwent primary PCI (N=120) were randomly assigned to three groups: the nicorandil-treated group (N=40) had 2 mg of nicorandil injected into the coronary artery at 2 mm beyond the occlusion with balloon pre-dilation; the sodium nitroprusside-treated group (N=40) underwent the same procedure, but with 200 µg of sodium nitroprusside; the control group (N=40) received PCI and balloon pre-dilation only. Coronary angiography, incidence of NRP, hypotensive episodes, ST-segment resolution (STR) rate, levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), creatine kinase-MB (CK-MB), cardiac troponin I (cTnI), wall motion score index (WMSI), and left ventricular ejection fraction (LVEF) were measured before and after primary PCI. Major adverse cardiovascular events (MACEs) post-PCI and at three-month follow-up were recorded. RESULTS Patients in the sodium nitroprusside and nicorandil groups had significantly improved thrombolysis in myocardial infarction (TIMI) scores, TIMI myocardial perfusion grade (TMPG), and ST-segment elevation resolution (STR) (P<0.05), and a significantly lower incidence of NRP (P=0.013). The incidence of intraoperative hypotension in the sodium nitroprusside group was significantly greater than the nicorandil and control groups (P=0.035). CONCLUSIONS Patients with sustained acute STEMI undergoing primary PCI, treated with intracoronary nicorandil had a reduced incidence of the NRP, improved myocardial perfusion and cardiac function.


Assuntos
Nicorandil/uso terapêutico , Fenômeno de não Refluxo/tratamento farmacológico , Fenômeno de não Refluxo/prevenção & controle , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fenômeno de não Refluxo/diagnóstico por imagem , Fenômeno de não Refluxo/cirurgia , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem
18.
Medicine (Baltimore) ; 97(21): e10850, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29794782

RESUMO

The aim of this study was to compare the efficacy and safety of 2 approaches for intra-coronary administration of tirofiban (aspiration catheter versus guiding catheter) in patients over 60 years of age undergoing percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). It has been suggested that the administration of tirofiban by intra-coronary injection could promote drug absorption in the diseased region and enhance the inhibition of platelet aggregation, decreasing bleeding rates, but little is known about the comparative efficiency and safety of using guiding catheter versus aspiration catheter for delivery.Eighty-nine patients over 60 years of age with STEMI undergoing PCI were randomly divided into 2 groups according to the injection route for intracoronary administration of tirofiban [guiding catheter (n = 41) and aspiration catheter (n = 48)]. Baseline features, epicardial and myocardial perfusion, major adverse cardiac and cerebrovascular events (MACCEs), and bleeding rate were compared.No differences in age, gender, and history of hypertension, hypercholesterolemia, diabetes, and so on were observed (P > .05). The patients in the aspiration catheter group generally had a higher incidence of cerebral vascular disease. Compared with those in the guiding catheter group, patients in the aspiration catheter group obtained more favorable myocardial perfusion (P < .05). In-hospital and at 3-month and 6-month follow-ups, the MACCE rate and frequency of bleeding events were similar between the 2 groups (P > .05).Intra-coronary delivery of tirofiban through aspiration catheter led to better myocardial perfusion in STEMI patients over 60 years of age undergoing PCI compared with intra-coronary injection of tirofiban through guiding catheter. The 2 delivery routes were associated with similar rates of MACCEs and bleeding events.


Assuntos
Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Tirosina/análogos & derivados , Idoso , Idoso de 80 Anos ou mais , Angiografia , Angioplastia Coronária com Balão/métodos , Cateteres/estatística & dados numéricos , Cateteres/tendências , Vias de Administração de Medicamentos , Feminino , Hemorragia/tratamento farmacológico , Hemorragia/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Imagem de Perfusão do Miocárdio/instrumentação , Miocárdio/metabolismo , Inibidores da Agregação de Plaquetas/uso terapêutico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/mortalidade , Tirofibana , Resultado do Tratamento , Tirosina/administração & dosagem , Tirosina/uso terapêutico
19.
Am J Cardiovasc Drugs ; 18(4): 299-309, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29691803

RESUMO

PURPOSE: The aim was to evaluate prognostic value of beta-blocker (BB) administration in acute coronary syndromes (ACS) patients in the percutaneous coronary intervention (PCI) era. METHODS AND RESULTS: The BleeMACS project is a multicenter, observational, retrospective registry enrolling patients with ACS worldwide in 15 hospitals. Patients discharged with BB therapy were compared to those discharged without a BB before and after propensity score with matching. The primary endpoint was all-cause mortality at 1 year. Secondary endpoints included in-hospital reinfarction, in-hospital heart failure, 1-year myocardial infarction, 1-year bleeding and 1-year composite of death and recurrent myocardial infarction. After matching, 2935 patients for each group were enrolled. The primary endpoint of 1-year death was significantly lower in the group on BB therapy (4.5 vs 7%, p < 0.05), while only a trend was noted for recurrent acute myocardial infarction (4.5 vs 4.9%, p = 0.54). These results were consistent for patients older than 80 years of age, for ST-elevation myocardial infarction (STEMI) patients, and for those discharged with complete versus incomplete revascularization, but not for non-STEMI/unstable angina patients. CONCLUSIONS: BB therapy was related to 1-year lower risk of all-cause mortality, independently from completeness of revascularization, admission diagnosis, age and ejection fraction. Randomized controlled trials for patients treated with PCI for ACS should be performed.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/terapia , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Intervenção Coronária Percutânea/métodos , Pontuação de Propensão , Sistema de Registros , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Resultado do Tratamento
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