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Biomedical subjects

C L Grines

Publications and source records attributed to C L Grines.

At least 55 records · Page 3Linked to original sources
PubMed1998

A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Results of the medicine versus angiography in thrombolytic exclusion (MATE) trial.

OBJECTIVES: The purpose of this study was to determine if early triage angiography with revascularization, if indicated, favorably affects clinical outcomes in patients with suspected acute myocardial infarction who are ineligible for thrombolysis. BACKGROUND: The majority of patients with acute myocardial infarction and other acute coronary syndromes are considered ineligible for thrombolysis and therefore are not afforded the opportunity for early reperfusion. METHODS: This multicenter, prospective, randomized trial evaluated in a controlled fashion the outcomes following triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Eligible patients (n=201) with <24 h of symptoms were randomized to early triage angiography and subsequent therapies based on the angiogram versus conventional medical therapy consisting of aspirin, intravenous heparin, nitroglycerin, beta-blockers, and analgesics. RESULTS: In the triage angiography group, 109 patients underwent early angiography and 64 (58%) received revascularization, whereas in the conservative group, 54 (60%) subsequently underwent nonprotocol angiography in response to recurrent ischemia and 33 (37%) received revascularization (p=0.004). The mean time to revascularization was 27+/-32 versus 88+/-98 h (p=0.0001) and the primary endpoint of recurrent ischemic events or death occurred in 14 (13%) versus 31 (34%) of the triage angiography and conservative groups, respectively (45% risk reduction, 95% CI 27-59%, p=0.0002). There were no differences between the groups with respect to initial hospital costs or length of stay. Long-term follow-up at a median of 21 months revealed no significant differences in the endpoints of late revascularization, recurrent myocardial infarction, or all-cause mortality. CONCLUSIONS: Early triage angiography in patients with acute coronary syndromes who are not eligible for thrombolytics reduced the composite of recurrent ischemic events or death and shortened the time to definitive revascularization during the index hospitalization. Despite more frequent early revascularization after triage angiography, we found no long-term benefit in cardiac outcomes compared with conservative medical therapy with revascularization prompted by recurrent ischemia.

Adult↗
PubMed1998

Scraping of aortic debris by coronary guiding catheters: a prospective evaluation of 1,000 cases.

OBJECTIVES: This study was designed to determine the incidence and to quantitate aortic debris retrieved during placement of guiding catheters in patients undergoing percutaneous interventions. BACKGROUND: Studies have shown that atherosclerotic aortic debris predisposes patients to spontaneous or procedurally related ischemic events. METHODS: In 1,000 consecutive percutaneous interventions, the amount of visible atheromatous material from large-lumen-guiding catheters was recorded. Clinical characteristics and in-hospital complications were prospectively collected and associated with debris production. RESULTS: Visible aortic debris (1+ to 3+) occurred more frequently with the Judkins left (JL) catheter, followed by the multipurpose (Multi) catheter compared to any other type of guiding catheter (65%, p = 0.001 and 60%, p = 0.01, respectively). Large debris (2+ and 3+) was observed most frequently with the Multi (odds ratio 3.79, C.I. = 2.32 to 6.21, p = 0.001), JL (odds ratio 2.83, C.I. = 1.98 to 4.05, p = 0.001) and voda left (VL) (odds ratio 2.73, C.I. = 1.51 to 4.95, p = 0.001) catheters. The Judkins right (JR) catheter type was least likely to produce any debris (24%, p = 0.001). A history of unstable angina (p = 0.05) or myocardial infarction (p = 0.003) was associated with a decreased incidence of debris production. The presence of debris was not found to be associated with in-hospital ischemic complications. CONCLUSIONS: Studies have shown that atherosclerosis of the aorta is a potential source of systemic embolism in patients undergoing cardiac catheterization. Our study shows that in more than 50% of percutaneous revascularization procedures, guiding catheter placement is associated with scraping debris from the aorta. Design characteristics of the JL, Multi and VL guiding catheters make them most likely to produce such debris. Meticulous attention to allow the debris to exit the back of the catheter is essential to prevent injecting atheromatous debris into the vascular bed.

Aged↗
PubMed1997

Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review.

OBJECTIVE: To provide a quantitative review of the treatment effects of primary coronary angioplasty vs intravenous thrombolysis for acute myocardial infarction. DATA SOURCES: Ten randomized trials were identified through computerized bibliographic search of MEDLINE from January 1985 through March 1996 and by queries of principal investigators. STUDY SELECTION: Single-center and multicenter randomized trials comparing primary angioplasty with intravenous thrombolytic therapy among 2606 patients were included. Four trials compared angioplasty with streptokinase, 3 compared angioplasty with a 3- to 4-hour infusion of tissue-type plasminogen activator, and 3 compared angioplasty with "accelerated" administration of tissue-type plasminogen activator over 90 minutes. DATA EXTRACTION: Each investigator provided definitions and exact data for outcome events. Odds ratios (ORs), 95% confidence intervals (CIs), and P values were calculated using exact tests for categorical data. DATA SYNTHESIS: Mortality at 30 days or less was 4.4% for the 1290 patients treated with primary angioplasty compared with 6.5% for the 1316 patients treated with thrombolysis (34% reduction; OR, 0.66; 95% CI, 0.46-0.94; P=.02). The effect was similar among thrombolytic regimens, and no subgroup demonstrated a significant reduction in death. The rates of death or nonfatal reinfarction were 7.2% for angioplasty and 11.9% for thrombolytic therapy (OR, 0.58; 95% CI, 0.44-0.76; P<.001). Angioplasty was associated with a significant reduction in total stroke (0.7% vs 2.0%; P=.007) and hemorrhagic stroke (0.1% vs 1.1%; P<.001). CONCLUSIONS: Based on outcomes at hospital discharge or 30 days, primary angioplasty appears to be superior to thrombolytic therapy for treatment of patients with acute myocardial infarction, with the proviso that success rates for angioplasty are as good as those achieved in these trials. Data evaluating longer-term outcomes, operator experience, and time delay before treatment are needed before primary angioplasty can be universally recommended as the preferred treatment.

Angioplasty, Balloon, Coronary↗
PubMed1997

Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.

BACKGROUND: Coronary artery bypass surgery (CABG) has been considered the therapy of choice for patients with unprotected left main (ULMT) coronary stenoses. Selected single-center reports suggest that the results of percutaneous intervention may now approach those of CABG. METHODS AND RESULTS: To assess the results of percutaneous ULMT treatment from a wide variety of experienced interventional centers, we requested data on consecutive patients treated after January 1, 1994, from 25 centers. One hundred seven patients were identified who were treated either electively (n=91) or for acute myocardial infarction (n=16). Of patients treated electively, 25% were considered inoperable, and 27% were considered high risk for bypass surgery. Primary treatment included stents (50%), directional atherectomy (24%), and balloon angioplasty (20%). Follow-up was 98.8% complete at 15+/-8 months. Results varied considerably, depending on presentation and treatment. For patients with acute myocardial infarction, technical success was achieved in 75%, and survival to hospital discharge was 31%. For elective patients, technical success was achieved in 98.9%, and in-hospital survival was strongly correlated with left ventricular ejection fraction (P=.003). Longer-term event (death, infarction, or bypass surgery) -free survival was correlated with ejection fraction (P<.001) and was inversely related to presentation with progressive or rest angina (P<.001). Surgical candidates with ejection fractions > or = 40% had an in-hospital survival of 98% and a 9-month event-free survival of 86+/-5%, whereas patients with ejection fractions < 40% had 67% and 22+/-12% in-hospital and 9-month event-free survivals, respectively. Nine hospital survivors (10.6%) experienced cardiac death within 6 months of hospital discharge. CONCLUSIONS: While results for selected patients appear promising, until early post-hospital discharge cardiac death can be better understood and minimized, percutaneous revascularization of ULMT stenosis should not be considered an alternative to bypass surgery for most patients. When percutaneous revascularization of ULMT is required, directional atherectomy and stenting appear to be the preferred techniques, and follow-up angiography 6 to 8 weeks after treatment is probably advisable.

Aged↗
PubMed1997

Incidence and angiographic predictors of side branch occlusion following high-pressure intracoronary stenting.

We evaluated the incidence, angiographic predictors, and clinical outcome of side branch occlusion (SBO) following high-pressure intracoronary stenting in 175 patients. All stent implants during a 7-month period were reviewed for the incidence of major (>1 mm) SBO. Side branches were further characterized based on side branch and index lesion morphology. Clinical events (death, myocardial infarction, and target vessel revascularization rates) were determined at 9 months. A total of 175 patients (182 lesions) had 224 major side branches covered by intracoronary stents. Of these, 43 (19%) occluded. Most SBOs (29 of 43 [67%]) occurred after poststent dilation using high-pressure inflations (15.3 +/- 3.3 atmospheres). No clinical characteristics correlated with SBO. By multivariate analysis, those side branches with >50% ostial narrowing that arose from within or just beyond the diseased portion of the parent vessel (threatened side branch morphologies) were a powerful angiographic predictor of SBO (odds ratio 40, 95% confidence interval, 14 to 130, p <0.0001). At 9-month follow-up there was no difference in combined clinical events between those patients with and without SBO. These data demonstrate that side branches with ostial stenoses in continuity with diseased parent lesions were at risk of occlusion following stenting. SBO, however, was not associated with adverse clinical outcome. These findings lend support to plaque shift ("snow plow effect") as the mechanism behind SBO following stent placement.

Aged↗
PubMed1997

Rapid bedside coronary angiography with a portable fluoroscopic imaging system.

The ability to perform coronary angiography rapidly at the bedside has multiple potential applications. This study was designed to determine whether a novel portable angiographic system (OEC Medical Systems, series 9600, Salt Lake City, Utah) is capable of producing high-quality angiograms. In 29 patients (70 vessels) undergoing elective catheterization in a conventional fixed laboratory (Siemens HICOR, Erlangen, Germany), we compared images obtained with the portable system to those from conventional fixed system. The portable system was 100% accurate in detecting both insignificant narrowing as well as significant stenoses (> 50% narrowing). There was complete concordance between systems for lesion location, TIMI flow, and collaterals. Thirty-two stenoses were analyzed in detail. Both quantitative and qualitative percent stenosis demonstrated similar value for lesion severity with both systems (R = 0.95, Kappa = 0.77, P < 0.001, respectively). Accuracy of lesion morphology by the portable system was similar to the fixed system (calcification 80%, eccentricity 92%). These findings demonstrate that a portable imaging system can produce high-quality coronary angiograms.

Adult↗
PubMed1997

Primary angioplasty reduces risk of myocardial rupture compared to thrombolysis for acute myocardial infarction.

Although the mechanical complications of acute ventricular septal defect and acute mitral regurgitation are uncommon after acute myocardial infarction, these complications are associated with an extremely high morbidity and mortality. We hypothesized that the administration of thrombolytic drugs may result in hemorrhagic infarction as well as the potential for incomplete revascularization and thus may lead to an increased incidence of mechanical complications compared to primary angioplasty. Accordingly, we reviewed the data of the most contemporary thrombolytic and primary angioplasty trials and compared the incidence of mechanical complications among 36,303 patients treated with thrombolytics reported in the GUSTO trial to the incidence of mechanical complications among 1,295 patients treated with primary angioplasty obtained from the PAMI-1 and PAMI-2 trials. We found that angioplasty resulted in an overall 86% relative risk reduction in mechanical complications (2.20% vs. 0.31%, P < 0.001). In comparison to thrombolytic therapy, angioplasty resulted in an 82% decrease in acute mitral regurgitation (1.73% vs. 0.31%, P < 0.001) and a 100% decrease in acute ventricular septal defect (0.47% vs. 0.00%, P < 0.03). In conclusion, in patients with acute myocardial infarction, reperfusion with primary angioplasty is associated with less myocardial rupture and mechanical complications than thrombolytics. This finding may, in part, explain the improved prognosis observed in myocardial infarction patients treated with primary angioplasty.

Adult↗
PubMed1997

Noninvasive prediction of residual blood flow within the risk area during acute myocardial infarction: a multicenter validation study of patients undergoing direct coronary angioplasty.

BACKGROUND: In a previous study from a single center, radionuclide measures of collateral flow with technetium 99m sestamibi have been shown to be significantly associated with angiographic residual (antegrade and collateral) flow and independent predictors of final infarct size in acute myocardial infarction. This study examined whether the previously described radionuclide measures of blood flow to the infarct zone were reproducible with different laboratories and imaging systems. METHODS AND RESULTS: Residual flow to the infarct zone was assessed by both invasive and noninvasive methods in 77 patients with first-time myocardial infarction (32 anterior, 45 nonanterior). All patients underwent acute coronary angiography before any intervention within 8 hours of the onset of chest pain (4.0 +/- 1.5 hours; range 1.2 to 7.9 hours). 99mTc sestamibi was injected intravenously before reperfusion therapy, and tomographic imaging was performed 1 to 6 hours after injection. A central core laboratory processed the acquired images from three centers, each with a unique camera and computer system. Three previously published methods based on the severity of the acute perfusion defect were used to measure residual flow to the infarct zone (nadir, severity index, area). Antegrade (Thrombolysis in Myocardial Infarction flow) and collateral flow before direct angioplasty were blindly graded on a four-point scale (0 to 3) from the acute angiogram. The simple sum of the two grades was defined as the angiographic flow index, representing residual flow to the jeopardized zone. All three noninvasive measures of residual flow were highly associated with the angiographic flow index in a linear fashion: severity index (p = 0.0006), area (p = 0.003), and nadir (minimum/maximum counts; p = 0.004). This association was independent of the laboratory where the data were acquired. CONCLUSIONS: Despite different laboratories and camera systems, radionuclide measures of residual flow were highly associated with the angiographic flow index before reperfusion therapy. These results suggest that these measures are applicable on a broader scale for the noninvasive determination of collateral and antegrade flow in acute myocardial infarction.

Coronary Angiography↗
PubMed1997

Analysis of the relative costs and effectiveness of primary angioplasty versus tissue-type plasminogen activator: the Primary Angioplasty in Myocardial Infarction (PAMI) trial. The PAMI Trial Investigators.

OBJECTIVES: We sought to determine the relative cost and effectiveness of two different reperfusion modalities in patients with acute myocardial infarction (AMI). BACKGROUND: Recent studies have found superior clinical outcomes after reperfusion by primary percutaneous transluminal coronary angioplasty (PTCA) compared with thrombolytic therapy. The high up-front costs of cardiac catheterization may diminish the relative advantages of this invasive strategy. METHODS: Detailed in-hospital charge data were available from all 358 patients with AMI randomized to tissue-type plasminogen activator (t-PA) or primary PTCA in the United States from the Primary Angioplasty in Myocardial Infarction trial. Resource consumption during late follow-up was estimated by assessment of major clinical events and functional status. RESULTS: Compared with t-PA, primary PTCA resulted in reduced rates of in-hospital mortality (2.3% vs. 7.2%, p = 0.03), reinfarction (2.8% vs. 7.2%, p = 0.06), recurrent ischemia (11.3% vs. 28.7%, p < 0.0001) and stroke (0% vs. 3.9%, p = 0.02) and a shorter hospital stay (7.6 +/- 3.3 days vs. 8.4 +/- 4.7 days, p = 0.04). Despite the initial costs of cardiac catheterization in all patients with the invasive strategy, total mean (+/- SD) hospital charges were $3,436 lower per patient with PTCA than with t-PA ($23,468 +/- $13,410 vs. $26,904 +/- $18,246, p = 0.04), primarily due to the reduction in adverse in-hospital outcomes. However, professional fees were higher after primary PTCA ($4,185 +/- $3,183 vs. $3,322 +/- $2,728, p = 0.001), and thus total charges, although favoring PTCA, were not significantly different ($27,653 +/- $13,709 vs. $30,227 +/- 18,903, p = 0.21). At a mean follow-up time of 2.1 +/- 0.7 years, no major differences in postdischarge events or New York Heart Association functional class were present between PTCA- and t-PA-treated patients, suggesting similar late resource consumption. Including in-hospital events, 83% of PTCA-treated patients were alive and free of reinfarction at late follow-up, compared with 74% of t-PA-treated patients (p = 0.06). CONCLUSIONS: Compared with t-PA, reperfusion by primary PTCA improves clinical outcomes with similar or reduced costs. These findings have important clinical implications in an increasingly cost-conscious health care environment.

Aged↗
PubMed1997

A prospective, randomized evaluation of prophylactic intraaortic balloon counterpulsation in high risk patients with acute myocardial infarction treated with primary angioplasty. Second Primary Angioplasty in Myocardial Infarction (PAMI-II) Trial Investigators.

OBJECTIVES: A large, international, multicenter, prospective, randomized trial was performed to determine the role of prophylactic intraaortic balloon pump (IABP) counterpulsation after primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI). BACKGROUND: Previous studies have suggested that routine IABP use after primary PTCA reduces infarct-related artery reocclusion, augments myocardial recovery and improves clinical outcomes. METHODS: Cardiac catheterization was performed in 1,100 patients within 12 h of onset of AMI at 34 clinical centers. Clinical and angiographic variables were used to stratify patients undergoing primary PTCA into high and low risk groups. High risk patients were then randomized to 36 to 48 h of IABP (n = 211) or traditional care (n = 226). The study had 80% power to detect a reduction in the primary end point from 30% to 20%. RESULTS: There was no significant difference in the predefined primary combined end point of death, reinfarction, infarct-related artery reocclusion, stroke or new-onset heart failure or sustained hypotension in patients treated with an IABP versus those treated conservatively (28.9% vs. 29.2%, p = 0.95). The IABP strategy conferred modest benefits in reduction of recurrent ischemia (13.3% vs. 19.6%, p = 0.08) and subsequent unscheduled repeat catheterization (7.6% vs. 13.3%, p = 0.05) but did not reduce the rate of infarct-related artery reocclusion (6.7% vs. 5.5%, p = 0.64), reinfarction (6.2% vs. 8.0%, p = 0.46) or mortality (4.3% vs. 3.1%) and was associated with a higher incidence of stroke (2.4% vs. 0%, p = 0.03). IABP use did not result in enhanced myocardial recovery as assessed by paired admission to predischarge and 6-week rest and exercise left ventricular ejection fraction. CONCLUSIONS: In contrast to previous studies, a prophylactic IABP strategy after primary PTCA in hemodynamically stable high risk patients with AMI does not decrease the rates of infarct-related artery reocclusion or reinfarction, promote myocardial recovery or improve overall clinical outcome.

Angioplasty, Balloon, Coronary↗
PubMed1997

PET perfusion and vasodilator function after angioplasty for acute myocardial infarction.

UNLABELLED: The aims of this study were to validate invasive coronary Doppler flows against noninvasive PET assessments of myocardial perfusion and to examine the timing and degree of regional coronary vasodilator reserve recovery in patients who are successfully reperfused with primary angioplasty (PTCA) for acute myocardial infarction. METHODS: PTCA was performed in 21 consecutive patients with acute myocardial infarction; the final diameter stenosis was 25% +/- 7%. After restoration of TIMI Grade 3 flow, all patients underwent quantitative coronary angiography and distal Doppler coronary blood flow studies (basal and after adenosine-induced hyperemia) in the infarct and noninfarct vessels. Regional myocardial perfusion and vasodilator function were quantitated after intravenous adenosine infusion PET in all patients at 26 +/- 9 hr after acute PTCA. These were repeated in 17 patients 9 +/- 3 days later. RESULTS: Post-PTCA resting coronary flow was 35 +/- 15 ml/min in the infarct-related vessels and 50 +/- 24 ml/min during peak hyperemia (p < 0.05). Coronary flow reserve (CFR) was 1.48 +/- 0.34 and 2.08 +/- 0.62 in the infarct and noninfarct vessels, respectively (p < 0.001). Early (< 36 hr) PET myocardial perfusion reserves (MPR) in the infarct and noninfarct regions were 1.59 +/- 0.33 and 2.03 +/- 0.62 (p < 0.01). Doppler CFR and PET MPR were correlated in the infarct (r = 0.61, p < 0.01) and noninfarct (r = 0.77, p < 0.0001) regions. Follow-up PET studies demonstrated improved MPR in both infarct and noninfarct regions (1.93 +/- 0.52 versus 2.54 +/- 0.97, p < 0.01). The improvement in coronary vasodilator function from the time of acute PTCA to follow-up PET in the infarct region was significant (p = 0.005). CONCLUSION: After successful mechanical revascularization by PTCA after acute myocardial infarction, intracoronary Doppler blood flows and noninvasive PET regional myocardial perfusion are correlated within the wide range of reperfusion blood flows observed in patients with contrast angiographic TIMI Grade 3 flow. Serial PET studies demonstrated a trend towards continued improvement in the vasodilator response in infarct-related myocardial regions after the restoration of blood flow by PTCA. PET offers the potential for accurate noninvasive serial assessment of reperfusion blood flow after primary angioplasty for acute myocardial infarction.

Angioplasty, Balloon, Coronary↗
PubMed1996

Optimal burr and adjunctive balloon sizing reduces the need for target artery revascularization after coronary mechanical rotational atherectomy.

We analyzed the effect of differing burr and balloon sizes during mechanical rotational atherectomy on the need for target vessel revascularization at 6 months. The ideal burr/artery ratio and adjunctive balloon/artery ratio for optimizing acute luminal results and minimizing restenosis is unknown. Six-month clinical follow-up was obtained in 311 patients (339 lesions) treated with rotational atherectomy from August 1993 to September 1994, to determine whether procedural results or technique were related to the need for target vessel revascularization. Target vessel revascularization, defined as repeat percutaneous intervention or bypass surgery within 6 months after rotational atherectomy, occurred in 19% of patients. Larger burr/artery ratios, defined as the final burr size divided by the reference artery size, were correlated with decreased postatherectomy diameter stenosis (p <0.009) and decreased final diameter stenosis (p <0.03). However, there was no statistical association between postatherectomy or final diameter stenosis with need for revascularization (p = not significant [NS]). The need for revascularization was lowest for burr/artery ratio between 0.6 to 0.85 (15%) versus burr/artery <0.6 or >0.85 (25%) (p <0.04). Postatherectomy, smaller balloon/artery ratios, defined as the final balloon size divided by the reference artery size, were correlated with lower repeat revascularization rates. Balloon/artery ratios <0.95 (target vessel revascularization = 11% vs 25% in balloon/artery >0.95) were associated with the best luminal results and the least risk for clinical restenosis (p <0.006). For rotational atherectomy, despite improvement in acute luminal results with increased burr/artery ratio, the use of a moderate burr/artery ratio correlated with the lowest revascularization rates. There was no correlation between postatherectomy or final diameter stenosis and need for repeat interventions. However, the use of large balloon/artery ratios after rotablator was associated with higher target vessel revascularization rates.

Aged↗
PubMed1996

Poloxamer-188 as an adjunct to primary percutaneous transluminal coronary angioplasty for acute myocardial infarction.

Poloxamer-188 is a surfactant polymer with antithrombotic and hemorheologic properties that make it potentially useful as an adjunct to acute reperfusion strategies. Animal studies and early human studies have documented poloxamer-188 to be effective at improving myocardial salvage when used as an adjunct to intravenous thrombolytic therapy for acute myocardial infarction. The current trial was a prospective pilot study involving 150 patients who were randomized in a 2:1 fashion to a poloxamer-188 infusion for 48-hours versus placebo. The poloxamer-188 infusion was well tolerated subjectively. The only clinically significant laboratory abnormality noted was an elevation in the serum creatinine above 2.0 g/dl in 12% (n = 12) of the 98 poloxamer-188 treated patients versus 1 of the 52 (2%) of the placebo treated patients (p = 0.048). Clinical end points including reinfarction (1% vs 4%), cardiogenic shock (7% vs 6%), and death (9% vs 4%) were statistically similar in the poloxamer-188 and placebo groups, respectively (p = NS). Using quantitative nuclear techniques, final infarct size and myocardial salvage were statistically similar in the poloxamer-188 and placebo groups. Mean left ventricular ejection fractions 1 week post after infarction were 51% +/- 12% in the poloxamer-188 group and 52% +/- 13% in the placebo group (p = NS). Final infarct size, was not altered by the poloxamer- 188 infusion; however, it was significantly correlated with normal perfusion (Thrombolysis in Myocardial Infarction grade 3 flow) in the infarct vessel after angioplasty. This study documented poloxamer-188 to be ineffective as an adjunct to primary angioplasty for acute myocardial infarction and resulted in azotemia in 12% of the patients.

Aged↗
PubMed1996

Effect of reperfusion modality on outcome in nonsmokers and smokers with acute myocardial infarction (a Primary Angioplasty in Myocardial Infarction [PAMI] substudy). PAMI Investigators.

We analyzed the 395 patients randomized into the Primary Angioplasty in Myocardial Infarction (PAMI) trial to receive tissue plasminogen activator (tPA) or to undergo primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI). Of these, 168 were current smokers and 128 had never smoked. Univariate analyses of baseline characteristics and outcome, including death, recurrent AMI, and recurrent ischemia, were done by chi-square analysis. Multivariate stratified analysis was then performed controlling for age and gender, which were found to be confounders of outcome. The combined in-hospital outcomes of death, recurrent AMI, and recurrent ischemia were similar for smokers and nonsmokers (p = 0.12). When stratified according to treatment modality, non-smokers treated with PTCA had a lower frequency of death and nonfatal recurrent AMI (7% vs 18%; p = 0.05), in-hospital ischemia (11% vs 33%; p = 0.004), or the combined event (13% vs 40%; p = 0.001). At 6 months, nonsmokers treated with PTCA continued to have a lower incidence of death or nonfatal recurrent AMI (11% vs 24%; p = 0.07) compared with tPA. Conversely, in smokers, the treatment strategy did not significantly affect hospital outcomes: recurrent ischemia (12% vs 23%; p = 0.07), death and recurrent AMI (6% vs 8%; p = 0.55), or the combined event (15% vs 25%; p = 0.12). The statistical significance of these associations was maintained when multivariate analysis controlling for age and gender was used. Thus, nonsmokers presenting with AMI had a significantly better outcome when treated with primary angioplasty; these differences were not seen in smokers.

Aged↗
PubMed1996

Prospective study of extraction atherectomy in patients with acute myocardial infarction.

Although percutaneous transluminal coronary angioplasty (PTCA) has been an effective treatment for primary reperfusion in acute myocardial infarction, patients with thrombolytic ineligibility, thrombolytic failure, cardiogenic shock, and vein graft occlusion remain at high risk for complications with PTCA treatment. The transluminal extraction catheter may be useful for treatment for such patients owing to its ability to aspirate thrombus. At 2 clinical centers, extraction atherectomy was prospectively evaluated in 100 patients (age 62 +/- 10 years). High-risk features included thrombolytic failure in 40%, postinfarct angina in 28%, presence of angiographic thrombus in 66%, presence of cardiogenic shock in 11%, and a saphenous vein graft occlusion in 29%. Procedural success, defined as a final residual stenosis <50% and Thrombolysis in Myocardial Infarction 2 or 3 grade flow, was seen in 94%. Events during the hospitalization included death in 5%, bypass surgery in 4%, and blood transfusion in 18%. In a substudy, patients enrolled at William Beaumont Hospital (n = 65) underwent elective predischarge angiography, which revealed a patent infarct-related vessel in 95%. These patients were also followed for 6 months with angiographic follow-up in 60%. Target vessel revascularization was necessary in 38%, and 6-month mortality was 10%. Although long-term vessel patency was 90%, angiographic restenosis occurred in 68%. Acute myocardial infarction patients can be treated with extraction atherectomy with a high technical success rate and a low incidence of complication. Infarct artery patency at 1 week and 6 months was excellent; however, angiographic restenosis remains a problem. Extraction of thrombus in this high-risk group of patients is associated with low in-hospital mortality and a high rate of vessel patency at 6 months.

Angina Pectoris↗
PubMed1996

Aggressive intervention for myocardial infarction: angioplasty, stents, and intra-aortic balloon pumping.

Primary percutaneous transluminal coronary angioplasty (PTCA) is not used in all hospitals capable of performing it because the data regarding results are either not known or not easily interpreted. Unlike pharmaceutical trials, which receive $30-50 million in research funds, virtually all trials of PTCA have been unfunded. Nevertheless, several groups have conclusively proved the benefit of primary PTCA over thrombolysis. In a 1995 meta-analysis, PTCA proved superior to thrombolytic therapy in reducing death and reinfarction. The Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-IIB) substudy confirmed this fact with 94% certainly. Other studies were designed to refine the angioplasty technique. In the Primary Angioplasty in Myocardial Infarction (PAMI-I) study, acute catheterization was used to stratify patients and identified a low-risk population whose mortality equaled that of patients treated electively. Compared with clinical risk factors, angiographic findings enhanced the power to predict mortality three-fold. The high-risk subset with acute myocardial infarction (MI) was also randomized to treatment with or without prophylactic intra-aortic balloon pumping (IABP). Although IABP caused no complications, it had no positive effect on primary endpoints (death, recurrent MI, and reocclusion) and did not improve left ventricular function at 6 months. One limitation of primary PTCA is a high rate of late restenosis (30-50% at 6 months). In a pilot study we are examining the role of stents in conjunction with primary PTCA. Early results indicate that in the 69% of patients eligible for stent placement, in-hospital events were uncommon (no deaths, no reinfarctions, low rate of recurrent ischemia) and the need for repeat revascularization was infrequent.

Angioplasty, Balloon, Coronary↗