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Temporal trends towards increased mortality despite Improved door-to-balloon times in ST-elevation myocardial infarction  

20 Dec, 14 | by Alistair Lindsay

A short door-to-balloon time (D2B) is considered a quality of care measure for patients of ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous intervention (pPCI). However, recent literature has documented reductions in D2B that were not associated with improved STEMI mortality. Using the National Cardiovascular Data Registry (NCDR) CathPCI Registry, Nallamothu et al. assessed this apparent contradiction at the individual and population levels. The authors examined 150,116 pPCI procedures performed on 146,940 patients at 423 US hospitals over the course of six years. They assessed both in-hospitality (in the entire cohort) and 6-month mortality (in Medicare beneficiaries ≥ 65 years old) using models that incorporated patient and population-level components relevant to the association between D2B time and outcomes. more…

No benefit to thrombus aspiration in STEMI

14 Oct, 14 | by Alistair Lindsay

Thrombus aspiration in acute ST-segment elevation myocardial infarction (STEMI) is clinically appealing and often used prior to PCI. However, the majority of trials evaluating thrombus aspiration have failed to demonstrate significant mortality benefit. The Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) trial is a multi-center study that randomized a total of 7244 presenting with a STEMI for primary PCI to either thrombus aspiration or PCI without prior aspiration. From this trial, the authors have previously reported no significant mortality difference at 30 days between routine thrombus aspiration and standard PCI. more…

Thrombus aspiration in STEMI fails to demonstrate benefit

29 Dec, 13 | by Alistair Lindsay

Thrombus aspiration during primary PCI for patients presenting with ST elevation myocardial infarction (STEMI) is an intuitively attractive manoeuvre to aid rapid reperfusion, reduce distal embolization and improve microvascular perfusion.  Despite limited trial evidence of clinical benefit, the procedure has quickly taken hold in many PCI centres with European and US guidelines agreeing on a IIa recommendation for its use. more…

Bivalirudin in contemporary STEMI treatment

29 Dec, 13 | by Alistair Lindsay

The novel direct thrombin inhibitor bivalirudin is now widely used as an adjunctive therapy in patients undergoing primary PCI for ST elevation myocardial infarction (STEMI). This stems from trial data demonstrating bivalirudin results in lower bleeding rates and better long term survival as compared with the combination of heparin and a GP IIb/IIIa inhibitor. However, clinical practice has subsequently changed, including greater use of radial access with resultant lower bleeding risk and expanded use of newer generation P2Y­12 inhibitors.  The EUROMAX trial sought to understand whether use of bivalirudin benefits patients in light of these changes in clinical practices. more…

Treatment of bystander coronary disease in primary PCI improves outcomes

22 Nov, 13 | by Alistair Lindsay

In patients with ST-elevation myocardial infarction (STEMI), current guidelines support PCI of the infarct related artery and medical management of flow-limiting lesions in non-infarct related vessels (so-called bystander disease). This paradigm is challenged in the Preventive Angioplasty in Acute Myocardial Infarction (PRAMI) study. In this single-blind trial performed at five UK centres, patients presenting with STEMI were randomly assigned to preventive PCI or no further PCI of non-infarct related vessels with >50% stenosis, immediately following reperfusion of the infarct related artery. The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina and the mean follow-up was 23 months. The trial was stopped early by the data and safety monitoring committee following enrolment of 465 out of a planned 600 patients due to a highly significant result favouring preventive PCI;  the primary outcome occurred in 21 patients assigned to preventive PCI and in 53 patients assigned to no preventive PCI.  This translates into an absolute risk reduction of 14% in the preventive PCI group (HR 0.35; 95% CI, 0.21 to 0.58; NNT 8; P<0.001). The hazard ratios were 0.34 (95% CI, 0.11 to 1.08) for death from cardiac causes, 0.32 (95% CI, 0.13 to 0.75) for nonfatal myocardial infarction, and 0.35 (95% CI, 0.18 to 0.69) for refractory angina.  Although procedure times and contrast loads were significantly higher in the preventive PCI group, this did not translate into an increase in procedure-related adverse events. more…

COMFORTABLE AMI: New-generation DES shows benefit

29 Aug, 12 | by Alistair Lindsay

Drug-eluting stents (DES) with biodegradable polymers can allow controlled drug release followed by subsequent degradation of the polymer, leaving a in essence a bare-metal stent.  In patients undergoing primary percutaneous coronary intervention (PCI) for acute ST-elevation myocardial infarction (STEMI), this may prevent the delayed vessel healing that is thought to be caused at least in part by the persistence of durable polymer components. more…

Intracoronary abciximab offers no extra benefit

4 Mar, 12 | by Alistair Lindsay

Despite the introduction of primary angioplasty programmes for patients with acute ST-elevation myocardial infarction (STEMI), up to 70% of patients have impaired myocardial tissue perfusion even after successful treatment.  As intracoronary delivery of abciximab results in much higher concentrations within the coronary artery when compared to intravenous administration, it is logical to propose that this could increase platelet inhibition, displacement of platelet-bound fibrin, and thrombi dissolution, which in turn could decrease distal embolisation and increase myocardial tissue perfusion.n  Should intracoronary injection of abciximab therefore be routine practice during primary percutaneous coronary intervention? more…

Use of evidence-based treatments improves STEMI outcomes

3 May, 11 | by Alistair Lindsay

Over the last two decades several new treatments, both pharmacological and mechanical, have become available for the treatment of ST-elevation myocardial infarction (STEMI).  As a result, several rounds of national and international guidelines have been developed to guide the implementation of these evidence-based treatments in clinical practice.  However, relatively few data are available on how implementation of such guidelines has influenced clinical outcomes. more…

Paclitaxel Stents Safe in STEMI

21 Jun, 09 | by Alistair Lindsay

The Harmonising Outcomes with Revascularisation and Stents in Acute Myocardial Infarction (HORIZONS-AMI) was a prospective open label, multi-centre controlled trial involving patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). It incorporated two factorial randomised phases to allow a comparison of the direct thrombin inhibitor bivalirudin alone with heparin plus glycoprotein IIb-IIIa inhibitor use and a comparison of paclitaxel eluting stents (PES) with bare metal stents (BMS). Two primary clinical end-points were pre-specified: ischaemia driven TLR (analysis powered for superiority) and a composite safety end-point of major adverse cardiovascular events consisting of death, reinfarction, stroke and stent thrombosis (powered for non-inferiority with a 3.0% margin). The major secondary end-point was angiographic evidence of restenosis at 13 months
more…

Prasugrel proves powerful in STEMI

14 Mar, 09 | by Alistair Lindsay

Prasugrel is novel third-generation thienopyridine which is a more potent blocker of the platelet P2Y12 receptor than clopidogrel.The TRITON-TIMI 38 (Trial to assess Improvement in Therapeutic Outcomes by optimizing platelet inhibition with prasugrel – Thrombolysis in Myocardial Infarction 38) study compared clopidogrel with prasugrel in the setting of ST elevation myocardial infarction (STEMI). more…

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