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Thrombolysis
Kinds of Thrombolysis Selected AbstractsPreconditioning and postconditioning: new strategies for cardioprotectionDIABETES OBESITY & METABOLISM, Issue 6 2008D. J. Hausenloy Despite optimal therapy, the morbidity and mortality of coronary heart disease (CHD) remains significant, particularly in patients with diabetes or the metabolic syndrome. New strategies for cardioprotection are therefore required to improve the clinical outcomes in patients with CHD. Ischaemic preconditioning (IPC) as a cardioprotective strategy has not fulfilled it clinical potential, primarily because of the need to intervene before the index ischaemic event, which is impossible to predict in patients presenting with an acute myocardial infarction (AMI). However, emerging studies suggest that IPC-induced protection is mediated in part by signalling transduction pathways recruited at time of myocardial reperfusion, creating the possibility of harnessing its cardioprotective potential by intervening at time of reperfusion. In this regard, the recently described phenomenon of ischaemic postconditioning (IPost) has attracted great interest, particularly as it represents an intervention, which can be applied at time of myocardial reperfusion for patients presenting with an AMI. Interestingly, the signal transduction pathways, which underlie its protection, are similar to those recruited by IPC, creating a potential common cardioprotective pathway, which can be recruited at time of myocardial reperfusion, through the use of appropriate pharmacological agents given as adjuvant therapy to current myocardial reperfusion strategies such as thrombolysis and primary percutaneous coronary intervention for patients presenting with an AMI. This article provides a brief overview of IPC and IPost and describes the common signal transduction pathway they both appear to recruit at time of myocardial reperfusion, the pharmacological manipulation of which has the potential to generate new strategies for cardioprotection. [source] Therapeutic Yield and Outcomes of a Community Teaching Hospital Code Stroke ProtocolACADEMIC EMERGENCY MEDICINE, Issue 4 2004Andrew W. Asimos MD Objectives: To describe the experience of a community teaching hospital emergency department (ED) Code Stroke Protocol (CSP) for identifying acute ischemic stroke (AIS) patients and treating them with tissue plasminogen activator (tPA) and to compare outcome measures with those achieved in the National Institute of Neurological Disorders and Stroke (NINDS) trial. Methods: This study was a retrospective review from a hospital CSP registry. Results: Over a 56-month period, CSP activation occurred 255 times, with 24% (n= 60) of patients treated with intravenous (IV) tPA. The most common reasons for thrombolytic therapy exclusion were mild or rapidly improving symptoms in 37% (n= 64), intracerebral hemorrhage (ICH) in 23% (n= 39), and unconfirmed symptom onset time for 14% (n= 24) of patients. Within 36 hours of IV tPA treatment, 10% (NINDS = 6%) of patients (n= 6) sustained a symptomatic ICH (SICH). Three months after IV tPA treatment, 60% of patients had achieved an excellent neurologic outcome, based on a Barthel Index of ,95 (NINDS = 52%), while mortality measured 12% (NINDS = 17%). Among IV tPA-treated patients, those developing SICH were significantly older and had a significantly higher mean initial glucose value. Treatment protocol violations occurred in 32% of IV tPA-treated patients but were not significantly associated with SICH (Fisher's exact test). Conclusions: Over the study period, the CSP yielded approximately one IV tPA-treated patient for every four screened and, despite prevalent protocol violations, attained three-month functional outcomes equal to those achieved in the NINDS trial. For community teaching hospitals, ED-directed CSPs are a feasible and effective means to screen AIS patients for treatment with thrombolysis. [source] Effect of daytime, weekday and year of admission on outcome in acute ischaemic stroke patients treated with thrombolytic therapyEUROPEAN JOURNAL OF NEUROLOGY, Issue 4 2010M. Jauss Background:, Since doubts were raised, if a challenging medical procedure such as acute stroke treatment including thrombolysis with recombinant tissue plasminogen activator (rTPA) is available with identical standard and outcome 24 h and 7 days a week our aim was to examine if acute stroke patients defined by onset-admission time (OAT) of , 3 h were treated differently or had distinct outcome when admitted during off duty hours (day versus night and weekend versus weekdays) and if any differences in treatment or outcome were apparent when comparing patients admitted in the year 2003 with patients admitted in the year 2006. Methods:, We analyzed 2003,2006 data of a prospective registry and grouped patients by time, day, and year of admission. The evaluation was limited to patients that were diagnosed with ischaemic stroke and with OAT of , 3 h. Medical and sociodemographic items, use of thrombolytic treatment, complications during clinical course and place of discharge were obtained. Clinical state on admission and discharge was assessed using the modified Rankin scale. Comparison with chi-square test, t -test and logistic regression was performed. Results:, Patient's characteristics, rate of thrombolysis, and outcome were independent from time or day of admission. Proportion of patients with good clinical state at discharge increased significantly from 2003 to 2006 together with a higher rate of rTPA treatment without increase of intracranial hemorrhage. Proportion of patients discharged in good clinical condition after rTPA treatment increased from 34% to 44%. Conclusions:, Stroke treatment in potential candidates for thrombolytic therapy revealed no impairment on weekend or at night already in 2003. During 4 years, it was possible to increase rate of rTPA treatment from 8.9% to 21.8% without increment of complications or death, confirming that rTPA is safe and can be implemented with full daily and weekly coverage. [source] Thrombolysis in patients with acute ischemic stroke due to arterial extracranial dissectionEUROPEAN JOURNAL OF NEUROLOGY, Issue 5 2009M. D. I. Vergouwen Background and purpose:, No data of randomized controlled trials investigating the effect of thrombolysis in patients with ischemic stroke caused by an extracranial dissection are available. Previous case series suggested that thrombolysis in this group of patients is safe and improves outcome, however publication bias may play a role. The purpose of the present study was to describe outcome of consecutive patients with ischemic stroke caused by an extracranial dissection treated with recombinant tissue plasminogen activator (rtPA), derived from a well-defined ischemic stroke cohort. Methods:, All consecutive patients with a transient ischemic attack (TIA) or ischemic stroke admitted to the Academic Medical Center Amsterdam between January 1, 2007 and September 1, 2007 were prospectively registered. Cause of TIA/stroke, treatment, and 6-months outcome were recorded. Results:, During the study period 252 patients were evaluated with TIA or ischemic stroke. Eight patients (3%) had an extracranial dissection. Of the six rtPA treated patients, five had good clinical outcome and one patient died. The two patients who were not treated with rtPA, because of minor stroke, had good clinical outcome 6 months after index event. Discussion:, Treatment with rtPA seems to be safe and feasible in ischemic stroke patients with an extracranial dissection. [source] Thrombotic occlusion of the common carotid artery (CCA) in acute ischemic stroke treated with intravenous tissue plasminogen activator (TPA)EUROPEAN JOURNAL OF NEUROLOGY, Issue 2 2007V. K. Sharma Although common carotid artery (CCA) occlusions are rare, acute clinical presentations vary from mild to devastating strokes primarily due to tandem occlusions in the intracranial arteries. Three patients with acute CCA occlusions were treated with systemic tissue plasminogen activator (TPA). Blood pressures were kept at the upper limits allowed with TPA therapy with fluid balance and the ,head-down' position. Recanalization occurred in intracranial vessels only. Marked early neurological improvement occurred in two of three patients. CCA occlusions should not be considered contra-indication to systemic thrombolysis. [source] EFNS guideline on neuroimaging in acute stroke.EUROPEAN JOURNAL OF NEUROLOGY, Issue 12 2006Report of an EFNS task force Neuroimaging techniques are necessary for the evaluation of stroke, one of the leading causes of death and neurological impairment in developed countries. The multiplicity of techniques available has increased the complexity of decision making for physicians. We performed a comprehensive review of the literature in English for the period 1965,2005 and critically assessed the relevant publications. The members of the panel reviewed and corrected an initial draft, until a consensus was reached on recommendations stratified according to the European Federation of Neurological Societies (EFNS) criteria. Non-contrast computed tomography (CT) scan is the established imaging procedure for the initial evaluation of stroke patients. However, magnetic resonance imaging (MRI) has a higher sensitivity than CT for the demonstration of infarcted or ischemic areas and depicts well acute and chronic intracerebral hemorrhage. Perfusion and diffusion MRI together with MR angiography (MRA) are very helpful for the acute evaluation of patients with ischemic stroke. MRI and MRA are the recommended techniques for screening cerebral aneurysms and for the diagnosis of cerebral venous thrombosis and arterial dissection. For the non-invasive study of extracranial vessels, MRA is less portable and more expensive than ultrasonography but it has higher sensitivity and specificity for carotid stenosis. Transcranial Doppler is very useful for monitoring arterial reperfusion after thrombolysis, for the diagnosis of intracranial stenosis and of right-to-left shunts, and for monitoring vasospasm after subarachnoid hemorrhage. Currently, single photon emission computed tomography and positron emission tomography have a more limited role in the evaluation of the acute stroke patient. [source] A pilot study on systemic thrombolysis followed by low molecular weight heparin in ischemic strokeEUROPEAN JOURNAL OF NEUROLOGY, Issue 10 2006R. Mikulík Low molecular weight heparin (LMWH) administered immediately after intravenous thrombolysis (IT) may reduce the risk of arterial re-occlusion. Its benefit, however, may not outweigh the risk of intracranial hemorrhage (ICH). We sought preliminary data regarding safety of this combined therapy in an open-label, non-randomized study. The patients received either a standard anticoagulation (AC) starting 24 h after IT (the standard AC group) or AC with 2850 IU of nadroparin, given every 12 h immediately after IT (the early AC group). Sixty patients received IT treatment: 25 in the standard AC group [mean age 66, median National Institutes of Health Stroke Scale (NIHSS) 13, 64% men] and 35 in the early AC group (mean age 68, median NIHSS 13, 69% men). Symptomatic ICH occurred in one patient (4%) in the standard AC group and three patients (8.6%) in the early AC group [odds ratio (OR) 1.8; 95%CI 0.2,12.8]. At 3 months, nine patients in the standard AC group (36%) and 16 patients in the early AC group (45.7%) achieved a modified Rankin scale 0 or 1 (OR 1.2; 95%CI 0.5,3.2). Our study suggests that treatment with LMWH could be associated with higher odds of ICH, although it may not necessarily lead to a worse outcome. This justifies larger clinical trials. [source] EFNS guideline on the treatment of cerebral venous and sinus thrombosisEUROPEAN JOURNAL OF NEUROLOGY, Issue 6 2006K. Einhäupl Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed due to the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis, and symptomatic therapy including control of seizures and elevated intracranial pressure. We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence, but consensus was clear we stated our opinion as good practice points. Patients with CVST without contraindications for anticoagulation should be treated either with body weight-adjusted subcutaneous LMWH or dose-adjusted intravenous heparin (good practice point). Concomitant intracranial haemorrhage related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulation after the acute phase is unclear. Oral anticoagulation may be given for 3 months if CVST was secondary to a transient risk factor, for 6,12 months in patients with idiopathic CVST and in those with ,mild' hereditary thrombophilia. Indefinite anticoagulation (AC) should be considered in patients with two or more episodes of CVST and in those with one episode of CVST and ,severe' hereditary thrombophilia (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate anticoagulation and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial haemorrhage (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. Antioedema treatment (including hyperventilation, osmotic diuretics and craniectomy) should be used as life saving interventions (good practice point). [source] Real-time monitoring of recanalization after intravenous thrombolysis for acute ischemic strokeEUROPEAN JOURNAL OF NEUROLOGY, Issue 4 2006R. Delgado-Mederos No abstract is available for this article. [source] Diabetes hyperglycemia and recovery from strokeGERIATRICS & GERONTOLOGY INTERNATIONAL, Issue 1-2 2001Christopher S Gray Strokeis a major cause of death and severe disability in older people. Despite the burden of disease, there is still no safe, simple and proven medical therapy for the treatment of acute stroke. Advances in acute stroke treatment have been either consistently disappointing (neuroprotective therapy) or fraught with controversy regarding risk/benefit (thrombolysis), and attention is once again being directed towards physiological variables that may influence outcome. Both insulin-dependent and non-insulin-dependent diabetes mellitus are major risk factors for stroke. Diabetes mellitus has also been shown to be associated with increased mortality and reduced functional outcome after stroke. Hyperglycemia is a frequent finding following stroke and may reflect the metabolic stress of the acute event, so-called stress hyperglycemia, and/or underlying impaired glucose metabolism. Several large clinical studies have now demonstrated a positive association between a raised blood glucose and poor outcome from stroke; greater mortality and reduced functional recovery. What is not clear is to what extent hyperglycemia is a ,normal' physiological response to stroke or whether hyperglycemia per se increases cerebral damage in the acute phase. There are many potential mechanisms by which hyperglycemia can exert a harmful effect upon cerebral tissue and it is probable that an important relationship exists, not only between glucose and stroke outcome, but also between insulin and neuroprotection. It remains to be determined whether lowering and maintaining ,normal' glucose levels in the immediate aftermath of stroke, combined with the administration of insulin as an acute treatment, can modify this outcome. [source] Preliminary Results from the Use of New Vascular Access (Hemaport) for HemodialysisHEMODIALYSIS INTERNATIONAL, Issue 1 2003J Ahlmén One of the most important factors for an optimal chronic hemodialysis is a well- functioning vascular access. Still the A-V-fistula is the best alternative. When repeated failures arise new access alternatives are needed. The Hemaport combines a PTFE-graft with a percutaneous housing of titan. Starting and stopping the dialysis session is simple and needle-free. The first clinical experiences are presented. Thirteen patients (m-age 60 years) in 6 centres had used the Hemaport system. Out of 11 functioning devices 7 were placed on the upper arm and 4 were located on the thigh. The total days in observation were 2.156 days with 769 dialysis sessions performed. Six patients had used the Hemaport system for more than 6 months. Mean blood flow was 364, range 100,450 ml/min with a mean venous and arterial pressure of 100 mm Hg, range 30,250, and 16 mm Hg respectively, range , 140 to + 259. Thrombosis interventions have been required in 14 percent to obtain a functioning vascular access. Two patients contributed with more than half of these events. Mechanical or pharmacological thrombolysis can be performed through the Hemaport dialysis lid without open surgery. Six implants have been removed and in 5 of these cases a new Hemaport was implanted. The reasons for removing the device were related to insufficient vascular flow, thrombosis, and/or infection. In patients with repeated access problems, a new vascular access (Hemaport) has been clinically used for about 1 year. By its design, Hemaport offers a novel approach. [source] The implementation of intravenous tissue plasminogen activator in acute ischaemic stroke , a scientific position statement from the National Stroke Foundation and the Stroke Society of AustralasiaINTERNAL MEDICINE JOURNAL, Issue 5 2009Ad Hoc Committee representing the National Stroke Foundation, the Stroke Society of Australasia Abstract Intravenous tissue plasminogen activator (tPA) has been licensed in Australia for thrombolysis in selected patients with acute ischaemic stroke since 2003. The use of tPA is low but is increasing across Australia and national audits indicate efficacy and safety outcomes equivalent to international benchmarks. Implementing tPA therapy in clinical practice is, however, challenging and requires a coordinated multidisciplinary approach to acute stroke care across prehospital, emergency department and inpatient care sectors. Stroke care units are an essential ingredient underpinning safe implementation of stroke thrombolysis. Support systems such as care pathways, therapy delivery protocols, and thrombolysis-experienced multidisciplinary care teams are also important enablers. Where delivery of stroke thrombolysis is being planned, health systems need to be re-configured to provide these important elements. This consensus statement provides a review of the evidence for, and implementation of, tPA in acute ischaemic stroke with specific reference to the Australian health-care system. [source] Acute stroke and transient ischaemic attack management , time to act fastINTERNAL MEDICINE JOURNAL, Issue 5 2009D. S. Crimmins Abstract Stroke is Australia's second single greatest killer with 53 000 new events each year at a rate of 1 every 10 min. Stroke services should be organized to enable people to access proven therapies, such as stroke unit care and thrombolysis, to reduce the impact of stroke. Timely, efficient and coordinated care from ambulance services, emergency services and stroke services will maximize recovery and prevent costly complications and subsequent strokes. Efficient management of patients with transient ischaemic attack can produce significant reductions in subsequent stroke events and risk stratification using the ABCD2 tool can aid management decisions. Evidence for acute stroke care continues to evolve and it is crucial that health professionals are aware of, and implement, best practice clinical guidelines for stroke care. [source] Is right heart thromboemboli another indication for thrombolysis?INTERNAL MEDICINE JOURNAL, Issue 5 2007R. Agarwal Abstract Pulmonary embolism (PE) is a common and a potentially life-threatening disease. Diagnosis is challenging because the signs and symptoms are non-specific. Moreover treatment of PE is shrouded in controversy. Even at presentation the role of thrombolysis in managing patients with PE remains unclear. In those patients with right heart thromboemboli, thrombolysis is usually suggested, but the evidence remains unclear. We report a 34-year-old man who was diagnosed with right heart thromboemboli on echocardiography and was successfully managed with thrombolysis and anticoagulation. We also review the current published work on the management of patients with right heart thromboemboli. [source] The challenge of thrombolysis for acute ischaemic stroke: can we treat more patients?INTERNAL MEDICINE JOURNAL, Issue 8 2006P. J. Hand No abstract is available for this article. [source] Calculation of sample size for stroke trials assessing functional outcome: comparison of binary and ordinal approachesINTERNATIONAL JOURNAL OF STROKE, Issue 2 2008The Optimising Analysis of Stroke Trials (OAST) collaboration Background Many acute stroke trials have given neutral results. Sub-optimal statistical analyses may be failing to detect efficacy. Methods which take account of the ordinal nature of functional outcome data are more efficient. We compare sample size calculations for dichotomous and ordinal outcomes for use in stroke trials. Methods Data from stroke trials studying the effects of interventions known to positively or negatively alter functional outcome , Rankin Scale and Barthel Index , were assessed. Sample size was calculated using comparisons of proportions, means, medians (according to Payne), and ordinal data (according to Whitehead). The sample sizes gained from each method were compared using Friedman 2 way ANOVA. Results Fifty-five comparisons (54 173 patients) of active vs. control treatment were assessed. Estimated sample sizes differed significantly depending on the method of calculation (P<0·0001). The ordering of the methods showed that the ordinal method of Whitehead and comparison of means produced significantly lower sample sizes than the other methods. The ordinal data method on average reduced sample size by 28% (inter-quartile range 14,53%) compared with the comparison of proportions; however, a 22% increase in sample size was seen with the ordinal method for trials assessing thrombolysis. The comparison of medians method of Payne gave the largest sample sizes. Conclusions Choosing an ordinal rather than binary method of analysis allows most trials to be, on average, smaller by approximately 28% for a given statistical power. Smaller trial sample sizes may help by reducing time to completion, complexity, and financial expense. However, ordinal methods may not be optimal for interventions which both improve functional outcome and cause hazard in a subset of patients, e.g. thrombolysis. [source] Promoting acute thrombolysis for ischaemic stroke (PRACTISE)INTERNATIONAL JOURNAL OF STROKE, Issue 2 2007Protocol for a cluster randomised controlled trial to assess the effect of implementation strategies on the rate, effects of thrombolysis for acute ischaemic stroke (ISRCTN 20405426) Rationale Thrombolysis with intravenous rtPA is an effective treatment for patients with ischaemic stroke if given within 3 h from onset. Generally, more than 20% of stroke patients arrive in time to be treated with thrombolysis. Nevertheless, in most hospitals, only 1,8% of all stroke patients are actually treated. Interorganisational, intraorganisational, medical and psychological barriers are hampering broad implementation of thrombolysis for acute ischaemic stroke. Aims To evaluate the effect of a high-intensity implementation strategy for intravenous thrombolysis in acute ischaemic stroke, compared with regular implementation; to identify success factors and obstacles for implementation and to assess its cost-effectiveness, taking into account the costs of implementation. Design The PRACTISE study is a national cluster-randomised-controlled trial. Twelve hospitals have been assigned to the regular or high-intensity intervention by random allocation after pair-wise matching. The high-intensity implementation consists of training sessions in conformity with the Breakthrough model, and a tool kit. All patients who are admitted with acute stroke and onset of symptoms not longer than 24 h are registered. Study outcomes The primary outcome measure is treatment with thrombolysis. Secondary outcomes are admission within 4 h after onset of symptoms, death or disability at 3 months, the rate of haemorrhagic complications in patients treated with thrombolysis, and costs of implementation and stroke care in the acute setting. Tertiary outcomes are derived from detailed criteria for the organisational characteristics, such as door-to-needle time and protocol violations. These can be used to monitor the implementation process and study the effectiveness of specific interventions. Discussion This study will provide important information on the effectiveness and cost-effectiveness of actively implementing an established treatment for acute ischaemic stroke. The multifaceted aspect of the intervention will make it difficult to attribute a difference in the primary outcome measure to a specific aspect of the intervention. However, careful monitoring of intermediate parameters as well as monitoring of accomplished SMART tasks can be expected to provide useful insights into the nature and role of factors associated with implementation of thrombolysis for acute ischaemic stroke, and of effective acute interventions in general. [source] The Surgical Option in the Management of Acute Pulmonary EmbolismJOURNAL OF CARDIAC SURGERY, Issue 6 2008Justo Rafael Sádaba F.R.C.S. (C/Th) Traditionally this condition has been treated with thrombolysis or anticoagulation and support measures. Surgical embolectomy is carried out in situations of hemodynamic instability or contraindication for thrombolysis. We present our results of surgical embolectomy in patients with massive and submassive PE. Methods: Over a three-year period, we have carried out 20 surgical embolectomies for acute PE. The mean age was 66 years, and there were 11 males. In all cases, the diagnosis had been made by a computerized tomography (CT) pulmonary artery angiography. Nine patients (45%) arrived to the operating theater on inotropes, and two of them (10%) with ventilatory support. All patients underwent a median sternotomy, bicaval cannulation for institution of cardiopulmonary bypass (CPB), and main pulmonary arteriotomy for the removal of the thrombus. Results: The mean bypass time was 45 minutes. Two patients (12%) died after being unable to wean off CPB due to right heart failure. Among the 15 survivors, the median ventilation time in the intensive care unit was 24 hours. Twelve patients (60%) required inotropic support postoperatively for right heart failure. All but one survivor (94%) underwent an insertion of a permanent inferior vena cava filter and were anticoagulated with coumarin. The mean follow-up is 9.8 months and is 100% complete, with a survival of 94.5%. All patients were in the World Health Organization (WHO) functional class I, with no re-admissions for respiratory failure. Conclusion: In patients with acute massive or submassive PE, surgical embolectomy offers a valid therapeutic strategy. A right-sided heart failure is the main complication of this condition. [source] Intracoronary enalaprilat during angioplasty for acute myocardial infarction: alleviation of postischaemic neurohumoral and inflammatory stress?JOURNAL OF INTERNAL MEDICINE, Issue 2 2007U. Schaefer Abstract. Aims., Reperfusion after myocardial ischaemia is associated with a distinct ischaemia/reperfusion injury. Since ACE-inhibition, beyond its influence on cardiac angiotensin II formation and kinin metabolism, has been shown to be cardioprotective by decreasing leucocyte adhesion and endothelin-1 (ET-1) release, we investigated the effects of intracoronary (i.c.) enalaprilat during primary angioplasty in acute myocardial infarction. Methods and Results., Twenty-two patients were randomized to receive i.c. enalaprilat (50 ,g) or placebo immediately after reopening of the infarct-related artery (IRA). Plasma concentrations of soluble L-selectin, P-selectin, intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), ET-1 and nitric oxide metabolite concentrations (NO(x)) were measured in pulmonary arterial blood. Coronary blood flow was assessed using corrected thrombolysis in myocardial infarction (TIMI) frame counts (CTFC). During reperfusion, there was a significant increase in sL-selectin, sP-selectin and ET-1 in the placebo group, which was greatly diminished by enalaprilat. Levels of sVCAM-1 and sICAM-1 were not affected in either group. CTFC in the placebo group remained higher than normal in both the IRA and nonculprit vessels, whereas myocardial blood flow improved with enalaprilat. Conclusion., Enalaprilat as adjunct to primary angioplasty might be a protective approach to prevent leucocyte adhesion and the release of ET-1, thereby improving coronary blood flow. [source] The risk of thrombolysis in association with cardiopulmonary resuscitation: no reason to withhold this causal and effective therapyJOURNAL OF INTERNAL MEDICINE, Issue 2 2003B. W. Böttiger No abstract is available for this article. [source] The Prognostic Value of Combined Fractional Flow Reserve and TIMI Frame Count Measurements in Patients with Stable Angina Pectoris and Acute Coronary SyndromeJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2010ALI M. ESEN M.D. Background:,The aim of this study was to evaluate the prognostic value of different fractional flow reserve (FFR) cutoff values and corrected thrombolysis in myocardial infarction frame (TIMI) count (CTFC) measurements in a series of consecutive patients with moderate coronary lesions, including patients with unstable angina, myocardial infarction, and/or positive noninvasive functional test findings. Methods:,We included 162 consecutive coronary patients in whom revascularization of a moderate coronary lesion was deferred based on a FFR value ,0.75. Patients were divided according to the results of the intracoronary pressure and flow measurements into four groups: group A: 0.75 , FFR , 0.85 and CTFC > 28 (n=22), group B: 0.75 , FFR , 0.85 and CTFC , 28 (n = 55), group C: 0.85 < FFR and CTFC > 28 (n = 19), and group D: 0.85 < FFR and CTFC , 28 (n = 66). Adverse cardiac events and the presence of angina were evaluated at follow-up. Results:,At a mean follow-up of 18 ± 10 months, cardiac event rate in patients with 0.75 , FFR , 0.85 and FFR > 0.85 were 22% and 9%, respectively (P = 0.026) and also, a trend was observed toward a higher cardiac event rate in case of an abnormal CTFC (CTFC > 28) compared to a normal CTFC (24% vs 12%, P = 0.066). Furthermore, a significantly higher cardiac event rate was observed when group A was compared to group D (31.8% vs 7.6%, respectively, P = 0.004). Conclusion:,Patients with potential microvascular dysfunction and borderline FFR values should be interpreted with caution, and management strategies should be guided not only by pressure measurement, but also by possibly supplementary clinical risk stratification and noninvasive tests. (J Interven Cardiol 2010;23:421,428) [source] No-Reflow Phenomenon Following Percutaneous Coronary Intervention for Acute Myocardial Infarction: Incidence, Outcome, and Effect of Pharmacologic TherapyJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2010F.A.C.C., F.A.C.P., SHEREIF H. REZKALLA M.D. Background: No-reflow (NR) phenomenon is a well-known problem, often accompanying percutaneous coronary intervention for acute ST elevation myocardial infarction (STEMI). There are little data on effects of pharmacologic therapy on the resolution, outcome, and long-term natural history of NR. Objective: Retrospectively assess incidence, management, and prognosis of NR in a tertiary referral hospital. Methods: Study included patients with STEMI, treated with percutaneous coronary intervention (PCI). Effect of pharmacologic therapy and long-term outcome were assessed. NR was defined by thrombolysis in myocardial infarction (TIMI) < 3 or myocardial blush grade (MBG) < 3. Results: Of 347 identified subjects, NR occurred in 110 (32%) by TIMI and 198 (57%) by MBG. Higher incidence was identified in men versus women (34% vs. 25% by TIMI, P = 0.08; and 60% vs. 48% by MBG, P = 0.04). Pharmacologic therapy was equally effective in restoring normal flow, increasing TIMI score from 1.62 ± 0.07 to 2.78 ± 0.06 (P < 0.0001) and MBG score from 0.43 ± 0.08 to 2.09 ± 0.11 (P < 0.0001). Twenty-three percent who did not receive pharmacologic therapy developed clinical composite of congestive heart failure, cardiogenic shock, and/or death; only 9% of patients who received pharmacologic therapy developed this composite. Patients with severe NR despite treatment had poorer prognosis. Sixty-five percent of patients who survived and had repeat angiogram about 1.5 years later had spontaneous improvement in coronary flow by MBG. Conclusion: NR is common in STEMI. Treatment with nicardipine, nitroprusside, and verapamil are equally effective in improving flow. If not treated, prognosis is poor. (J Interven Cardiol 2010;23:429,436) [source] Two-Year Clinical Registry Follow-up of Endothelial Progenitor Cell Capture Stent Versus Sirolimus-Eluting Bioabsorbable Polymer-Coated Stent Versus Bare Metal Stents in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial InfarctionJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2010ERIC CHONG M.B.B.S., F.A.M.S., M.R.C.P. Background: Endothelial progenitor cell (EPC) capture stent is designed to promote rapid endothelization and healing and is potentially useful in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). We studied the intermediate-term efficacy and safety of EPC stent and compared that with sirolimus-eluting bioabsorbable polymer stent (CURA) and bare metal stent (BMS) in AMI patients. Methodology: Patients presenting with AMI who underwent primary PCI with the respective stents between January 2004 and June 2006 were enrolled in the single-center clinical registry. The study end-points were major adverse cardiac events (MACE) and stent thrombosis. Results: A total of 366 patients (EPC = 95, CURA = 53, BMS 218) were enrolled. Baseline demographics including age, gender, diabetes, renal impairment, predischarge left ventricular ejection fraction, and creatinine kinase level were comparable among the groups. Procedural success rate was 99.5%. Post-procedural thrombolysis in myocardial infarction (TIMI) 3 flow was achieved in EPC 91.6%, CURA 96.2%, and BMS 88.5% (P = 0.209). At 2 years, the MACE rate was EPC 13.7%, CURA 15.1%, and BMS 19.7% (P = 0.383). Target vessel revascularizations (TVR) were EPC 4.2%, CURA 9.4%, and BMS 6.0% (P = 0.439). Nonfatal myocardial infarctions were EPC 1.1%, CURA 3.8%, and BMS 4.1% (P = 0.364). One patient in the EPC group had acute stent thrombosis. There was no late stent thrombosis in the EPC group. Conclusion: EPC stent appeared to be safe and had comparable clinical efficacy with a BMS when used in the AMI setting. At 2-year follow-up, the EPC group showed favorable, single-digit TVR rate and stent thrombosis remained a low-event occurrence. (J Interven Cardiol 2010;23:101-108) [source] Techniques for Acute Stroke InterventionJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 1 2009RAJAN A.G. PATEL M.D. Stroke or cerebrovascular accident is the second most common cause of death in Western countries. Although stroke is a treatable disease, the majority of patients do not receive intravenous thrombolysis or catheter-based therapy. The lack of treatment is multifactorial. Several treatments have been studied. Research and development in the area of acute stroke treatment are ongoing. [source] Racial Disparity in Clinical Outcomes Following Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction: Influence of Process of CareJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2007JOSHUA A. JACOBI M.D. Previous studies have shown that compared with white patients, non-white patients with STelevation myocardial infarction (STEMI) have worse clinical outcomes. Differences in co-morbidities, extent and severity of coronary artery disease, health insurance, and socioeconomic status have been identified as possible reasons for this disparity. However, an alternative explanation for such observed disparities in outcomes could be differences in process of care. For example, in most of these studies, non-white patients were less likely to receive reperfusion therapy, and if treated, were more likely to receive thrombolysis than to undergo primary percutaneous coronary intervention (PCI). We hypothesized that if all patients were treated similarly with primary PCI, there would be no difference in clinical outcomes. We analyzed the demographic, angiographic, in-hospital clinical outcomes, and long-term mortality rates of a racially diverse group of patients presenting to the same hospital with STEMI, all of whom were treated with primary PCI. Our data demonstrate that compared with white patients, non-white patients with STEMI who undergo primary PCI have similar in-hospital clinical outcomes and one-year mortality. This suggests that the previously observed differences in mortality rates may be, at least in part, attributable to differences in the process of care, and not solely to differences in patient factors or differential therapeutic effects. [source] Does Proximal Location of Culprit Lesion Confer Worse Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction?JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 4 2006KISHORE J. HARJAI M.D. ST segment elevation myocardial infarction (STEMI) from proximally located culprit lesion is associated with greater myocardium at jeopardy. In STEMI patients treated with thrombolytics, proximal culprit lesions are known to have worse prognosis. This relation has not been studied in patients undergoing primary percutaneous coronary intervention (PCI). In 3,535 STEMI patients with native coronary artery occlusion pooled from the primary angioplasty in myocardial infarction database, we compared in-hospital and 1-year outcomes between those with proximal (n = 1,606) versus nonproximal (n = 1,929) culprit lesions. Patients with proximal culprits were more likely to die and suffer major adverse cardiovascular events (MACE) during the index hospital stay (3.8% vs 2.2%, P = 0.006; 8.2% vs 5.8%, P = 0.0066, respectively) as well as during 1-year follow-up (6.9% vs 4.5%, P = 0.0013; 22% vs 17%, P = 0.003, respectively) compared to those with nonproximal culprits. After adjustment for baseline differences, proximal culprit was independently predictive of in-hospital death (adjusted odds ratio% 1.58, 95% confidence intervals, CI 1.05,2.40) and MACE (OR 1.41, CI 1.06,1.86), but not 1-year death or MACE. In addition, proximal culprit was independently associated with higher incidence of ventricular arrhythmias and sustained hypotension during the index hospitalization. The univariate impact of proximal culprit lesion on in-hospital death and MACE was comparable to other adverse angiographic characteristics, such as multivessel disease and poor initial thrombolysis in myocardial infarction flow, and greater than that of anterior wall STEMI. In conclusion, proximal location of the culprit lesion is a strong independent predictor of worse in-hospital outcomes in patients with STEMI undergoing primary PCI. [source] Acute Myocardial Infarction Complicated by Early Onset of Heart Failure:JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2003Feasibility of Interhospital Transfer for Coronary Angioplasty., Safety Objective: The objective of this study is to assess the feasibility and safety of interhospital transfer (within up to 60 minutes) for primary/rescue coronary angioplasty of patients with myocardial infarction (AMI) complicated by an early onset of acute heart failure (AHF) admitted to a community hospital without PCI facilities. Design and patients: From the multicenter randomized PRAGUE-1 study, a subgroup of 66 patients with AMI complicated by AHF on the first presentation to the community hospital were retrospectively analyzed. Group A patients(n = 21)were treated on site in community hospitals using thrombolysis (streptokinase), group B patients(n = 20)were transported with thrombolytic infusion to a PCI center for coronary angioplasty, and group C patients(n = 25)were immediately transported to a PCI center for primary angioplasty without thrombolysis. Results: No patient died during transportation. One group B patient developed ventricular fibrillation during transfer. The time delay from the onset of chest pain to reperfusion was >142 minutes, and 253 and 251 minutes in groups A, B, and C, respectively. Hospital stay (16 vs 11 vs 10 days,P = NS) was shorter in the angioplasty groups. Transported patients (groups B, C) displayed a significant decrease in heart failure progression within the first 24 hours after treatment (48% vs 15% vs 8%,P < 0.05). The combined end point, i.e., mortality + nonfatal reinfarction (43% vs 25% vs 8%,P < 0.05), was significantly less frequent in the coronary angioplasty group. Conclusions: Interhospital transfer for coronary angioplasty of patients with AMI complicated by an early onset of AHF is feasible and safe. Transport for angioplasty may even reduce the risk of heart failure progression and improve clinical outcome compared to immediate thrombolysis in the nearest community hospital. (J Interven Cardiol 2003;16:201,208) [source] Identification of Hemodynamically Significant Restenosis after Percutaneous Transluminal Coronary Angioplasty in Acute Myocardial Infarction by Transesophageal Dobutamine Stress Echocardiography and Comparison with Myocardial Single Photon Emission Computed TomographyJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2001STEPHAN ROSENKRANZ M.D. Background: Beside thrombolysis, percutaneous transluminal coronary angioplasty (PTCA) has become a well-established treatment for acute myocardial infarction. However, restenosis occurs in approximately 15%-40 % of patients. Despite a frequently occurring infarct-related regional systolic dysfunction at rest, the identification of hemodynamically relevant restenosis seems important in terms of risk stratification, adequate treatment, and possible improvement of prognosis in these patients. This study was designed to assess the role of transesophageal dobutamine stress echocardiography and myocardial scintigraphy for identification of hemodynamically significant restenosis after PTCA for acute myocardial infarction. Methods: Multiplane transesophageal stress echocardiography (dobutamine 5, 10, 20, 30, and 40 ,g/kg per min) studies and myocardial single photon emission computed tomography (SPECT) studies were performed in 40 patients, all of whom underwent PTCA in the setting of acute myocardial infarction , 4 months prior to the test. Repeated coronary angiography was performed in all study patients who showed stress-induced perfusion defects or wall-motion abnormalities, or both. Results: Significant restenosis (, 50%) was angiographically found in 15 (37.5%) of 40 patients. Of these 15 patients, transesophageal dobutamine stress echocardiography identified restenosis in 12 (80%) and myocardial SPECT in 14 (93%), yielding diagnostic agreement in 70% of patients. Echocardiographic detection of restenosis was based mainly on a biphasic response to increasing doses of dobutamine. Sensitivity and specificity for identification of hemodynamically relevant restenosis in individual patients was 80% and 92%, respectively for dobutamine stress echocardiography versus 93% and 68% for myocardial SPECT. Conclusions: Both transesophageal dobutamine stress echocardiography and myocardial SPECT were highly sensitive in identifying significant restenosis after PTCA for acute myocardial infarction. Therefore, either test, as a single diagnostic tool or especially if performed together, are clinically valuable alternatives to coronary angiography for the detection of restenosis after PTCA for acute myocardial infarction. [source] Acute Myocardial Infarction in a Discrete Coronary Artery Aneurysm Without ObstructionJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2000YUJI YOSHITOMI M.D. We report an unusual case of acute myocardial infarction attributable to obstruction of a discrete coronary aneurysm in a 54-year-old man. Although coronary angioplasty and thrombolysis were unsuccessful, serial arteriography showed spontaneous recanalization, and no spasm was induced by ergonovine. We discuss its mechanism. [source] Good neurological recovery after cardiopulmonary resuscitation and thrombolysis in two old patients with pulmonary embolismACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2009F. CAVALLARO The use of thrombolysis as an emergency treatment for cardiac arrest (CA) due to massive pulmonary embolism (MPE) has been described. However, there are no reports of successful treatment of MPE-associated CA in patients over 77 years of age. We report two cases of successful cardiopulmonary resuscitation for an MPE-associated CA in two very old women (87 and 86 years of age). In both cases, typical signs of MPE were documented using emergency echocardiography, which showed an acute right ventricle enlargement and a paradoxical movement of the interventricular septum. Emergency thrombolysis was administered during resuscitation, which lasted 45 and 21 min, respectively. Despite old age and prolonged resuscitation efforts, both patients had good neurological recovery and one of them was alive and neurologically intact 1 year later. Thrombolysis is a potentially useful therapy in MPE-associated CA. A good neurological outcome can be obtained even in very old patients and after prolonged resuscitation. [source] | ||||||||||||||||||||||||||||||||||