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1.
Am Heart J ; 141(4): 586-91, 2001 Apr.
Article in English | MEDLINE | ID: mdl-11275924

ABSTRACT

BACKGROUND: The majority of patients with patent infarct-related arteries after thrombolytic therapy have slower than normal flow, which relates to myocardial perfusion. METHODS: To evaluate the relationships between blood levels of creatine kinase (CK) and the corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (CTFC), infarct artery stenosis, and left ventricular function, we studied 397 patients with a first myocardial infarction who underwent angiography at 3 weeks. TIMI flow grades, the CTFC, infarct artery stenosis, and infarct zone wall motion (by contrast ventriculography using the centerline method) were assessed, and CK levels (in units per liter) were measured hourly for the first 4 hours after streptokinase (1.5 x 10(6) U over 30-60 minutes) and then every 4 hours over the next 20 hours, all blinded to treatment and outcome. RESULTS: Infarct artery stenosis and the CTFC, assessed as continuous variables, correlated in patients with patent infarct arteries (r = 0.33, P <.001). Also, there was a significant correlation between the CTFC and the sum of hypokinetic chords in the infarct zone (r = 0.15, P =.01). Patients with total occlusion or markedly slowed infarct artery flow (CTFC >100) had a higher fraction of chords with wall motion >2 SDs below normal (0.65 [0.41, 0.80] vs 0.37 [0.0, 0.67]) compared with patients with normal flow (CTFC < or =27) (P <.001). The rates of increase of median CK levels with respect to TIMI flow grades were 342 U/L/h for TIMI 3 versus 212 U/L/h for TIMI 2 versus 140 U/L/h for TIMI 0-1 (P <.0001). CONCLUSIONS: Prolonged corrected TIMI frame counts correlate with stenosis severity in the infarct artery after infarction, infarct zone regional wall motion, and CK levels.


Subject(s)
Coronary Vessels/physiopathology , Creatine Kinase/blood , Fibrinolytic Agents/therapeutic use , Myocardial Infarction/drug therapy , Myocardial Infarction/physiopathology , Streptokinase/therapeutic use , Thrombolytic Therapy , Constriction, Pathologic , Coronary Angiography , Coronary Vessels/pathology , Humans , Myocardial Infarction/pathology , Regional Blood Flow
3.
J Am Coll Cardiol ; 35(6): 1516-24, 2000 May.
Article in English | MEDLINE | ID: mdl-10807455

ABSTRACT

OBJECTIVES: To evaluate the corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (CTFC) as a predictor of late survival after myocardial infarction. BACKGROUND: Thrombolysis in Myocardial Infarction flow grades predict late survival after myocardial infarction. The CTFC provides a more reproducible measurement of infarct-related artery blood flow than the TIMI flow grade, and has been linked to 30-day outcomes, but it has not yet been established how the CTFC correlates with late survival. METHODS: Of 1,001 patients with acute myocardial infarction presenting within 4 h of symptom onset, 882 underwent angiography at approximately three weeks. Infarct artery flow was assessed, blinded to clinical outcomes, according to the CTFC and TIMI flow grade. Late cardiac mortality and survival were determined in 97.5% of patients. RESULTS: The mean CTFC was 40 +/- 29 in 644 patent infarct arteries (median, 34 [interquartile range, 24 to 47]). The CTFC, assessed as a continuous univariate variable, was found to be a predictor of five-year survival, as was the TIMI flow grade (both p < 0.001). On multivariate analysis, factors associated with five-year survival included the ejection fraction or end-systolic volume index (both p < 0.001); exercise duration (p = 0.005), age (p = 0.008), diabetes (p = 0.02) and CTFC (p = 0.02) or TIMI flow (p = 0.02). The same factors, except for the CTFC and TIMI flow grade, were predictors of 10-year survival. CONCLUSIONS: The CTFC three weeks after myocardial infarction was an independent predictor of five-year survival, but not 10-year survival. Although the CTFC provided additional prognostic information within TIMI flow grades, its superiority was not demonstrated.


Subject(s)
Myocardial Infarction/drug therapy , Thrombolytic Therapy , Adult , Aged , Blood Flow Velocity/drug effects , Coronary Angiography/drug effects , Coronary Circulation/drug effects , Female , Follow-Up Studies , Humans , Male , Middle Aged , Myocardial Infarction/mortality , Randomized Controlled Trials as Topic , Streptokinase/administration & dosage , Survival Rate , Tissue Plasminogen Activator/administration & dosage , Treatment Outcome
4.
J Am Coll Cardiol ; 34(1): 62-9, 1999 Jul.
Article in English | MEDLINE | ID: mdl-10399993

ABSTRACT

OBJECTIVES: The purpose of this study was to determine whether the mortality benefit of intravenous streptokinase administered within 4 h of the onset of acute myocardial infarction is maintained at 12 years, and whether Thrombolysis in Myocardial Infarction (TIMI) flow grades independently influence late survival. BACKGROUND: Treatment with reperfusion therapies and achievement of TIMI 3 flow are associated with increased short- and medium-term survival after infarction. Whether infarct artery flow independently influences survival more than five years after infarction is unknown. METHODS: The late survival of patients randomized to receive either streptokinase (1,500,000 IU over 30 to 60 min) or a matching placebo within 4 h of symptom onset in 1984-1986 was determined. Angiography was performed in surviving patients at three to four weeks, and TIMI flow grades were assessed blind to randomization and outcomes. The late vital status was determined in 99% of patients. RESULTS: Patients randomized to receive streptokinase (n = 107) had improved survival compared with those randomized to placebo (n = 112) at five years (84% vs. 70%; p = 0.023) and 12 years (66% vs. 51%; p = 0.022). At five years 94% of patients with TIMI grade 3 flow, 81% of those with TIMI grade 2 flow and 72% of those with TIMI grade 0-1 flow survived (p = 0.005). At 12 years 72% of patients with TIMI 3, 67% of those with TIMI 2 and 54% of those with TIMI 0-1 flow survived (p = 0.023). Multivariate analysis identified the ejection fraction (p = 0.014), exercise duration (p = 0.013) and TIMI 3 flow (p = 0.04 compared with TIMI 0-2 flow) as important factors for five-year survival. At 12 years multivariate predictors of late survival were the ejection fraction (p = 0.006), exercise duration (p = 0.003) and myocardial score (p = 0.013). The end-systolic volume index was similar to the ejection fraction as a predictor of survival at five and 12 years. CONCLUSIONS: The survival benefits of streptokinase persist for 12 years after infarction. TIMI flow at three to four weeks is an independent predictor of five-year survival.


Subject(s)
Fibrinolytic Agents/therapeutic use , Myocardial Infarction/drug therapy , Myocardial Infarction/mortality , Streptokinase/therapeutic use , Thrombolytic Therapy , Actuarial Analysis , Aged , Coronary Vessels/physiopathology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Myocardial Infarction/physiopathology , Randomized Controlled Trials as Topic , Regional Blood Flow , Survival Analysis , Treatment Outcome , Ventricular Function
5.
Heart ; 81(6): 586-92, 1999 Jun.
Article in English | MEDLINE | ID: mdl-10336915

ABSTRACT

OBJECTIVES: To review the New Zealand coronary artery bypass priority score instituted in May 1996, and specifically to determine whether it prioritizes patients at high risk of cardiac events while waiting. The New Zealand score is compared with the Ontario urgency rating score, and waiting times for surgery are compared with the maximum times recommended by the Ontario consensus panel. DESIGN: Retrospective review of patients accepted for isolated coronary artery bypass surgery between 1 January 1993 and 31 January 1996. SETTING: Green Lane Hospital, Auckland, New Zealand. MAIN OUTCOME MEASURES: Waiting time, cardiac death, myocardial infarction, and cardiac readmission. RESULTS: The median waiting times were five days for hospital cases (n = 721) and 146 days for out of hospital cases (n = 701). Of the latter group, 28% waited more than a year, 33% had their surgery expedited because of worsening symptoms, and 19% failed to meet the cut off point set by the New Zealand score for acceptance onto the list. Twenty two patients died, 18 on the outpatient waiting list (waiting list mortality 2.6%, risk 0.28% per month of waiting), and 132 were readmitted, 12% with myocardial infarction and 76% with unstable angina. Risk factors for a composite end point of death or myocardial infarction and/or cardiac readmission were: previous coronary artery bypass surgery (p = 0. 001), class III or IV angina (p = 0.002), and hypertension (p = 0. 005). The New Zealand score did not identify those at risk. Excluding hospital cases, 32% had surgery within the time recommended by the Ontario consensus panel. CONCLUSIONS: Waiting times for coronary artery bypass surgery in New Zealand are considerably longer than those in Ontario, Canada. By using a numerical cut off point, implementation of the New Zealand priority scoring system has restricted access to coronary surgery on the basis of funding constraints rather than clinical appropriateness. The score does not add greatly to the clinicians' prioritization in predicting those patients who will suffer events while waiting.


Subject(s)
Coronary Artery Bypass , Health Care Rationing/methods , Patient Selection , Severity of Illness Index , Waiting Lists , Adult , Aged , Coronary Disease/mortality , Coronary Disease/surgery , Female , Health Priorities , Humans , Male , Middle Aged , New Zealand/epidemiology , Ontario , Patient Readmission/statistics & numerical data , Retrospective Studies , Risk Factors , Time Factors
6.
J Am Coll Cardiol ; 33(1): 139-45, 1999 Jan.
Article in English | MEDLINE | ID: mdl-9935020

ABSTRACT

OBJECTIVES: To determine whether early administration of captopril lessens infarct zone regional wall motion abnormalities when infarct artery blood flow is abnormal. BACKGROUND: The interaction between angiotensin-converting enzyme (ACE) inhibitor therapy, ventricular function and infarct artery blood flow has not been well described. METHODS: A total of 493 patients aged < or = 75 years with first infarctions, presenting within 4 h of symptom onset, were randomized to receive 6.25 mg captopril, increasing to 50 mg t.d.s. or a matching placebo 2.1+/-0.4 h after commencing intravenous streptokinase (1.5 x 10(6) U over 30 to 60 min). Trial therapy was stopped 48 h prior to angiography at 3 weeks, to determine regional wall motion and infarct artery flow. RESULTS: There were no differences in ejection fractions or end-systolic volumes between patients randomized to receive captopril and those randomized to receive a placebo. Among patients with anterior infarction (n = 216), randomization to captopril resulted in fewer hypokinetic chords (40+/-13; vs. 44+/-13; p=0.028) and a trend toward fewer chords >2 SD below normal (26+/-17 vs. 30+/-17; p=0.052) in the infarct zone. In patients randomized to receive captopril who had anterior infarction and Thrombolysis in Myocardial Infarction (TIMI) 0-2, flow there were fewer hypokinetic chords (44+/-12 vs. 50+/-9; p=0.043) and a trend toward fewer chords >2 SD below normal (33+/-15 vs. 39+/-13; p=0.057). Patients receiving captopril who had anterior infarction and corrected TIMI frame counts > 27 had fewer hypokinetic chords (42+/-13 vs. 46+/-12; p=0.015) and fewer chords >2 SD below normal (27+/-17 vs. 32+/-17; p= 0.047). Captopril had no effect in patients with inferior infarction. There were 20 late cardiac deaths (median follow-up 4 years) in the captopril group and 35 in the placebo group (p=0.036). CONCLUSIONS: Randomization to receive captopril 2 h after streptokinase improved regional wall motion at 3 weeks. The greatest benefit was seen in patients with anterior infarction particularly when infarct artery blood flow is reduced.


Subject(s)
Angiotensin-Converting Enzyme Inhibitors/administration & dosage , Captopril/administration & dosage , Coronary Circulation/drug effects , Myocardial Contraction/drug effects , Myocardial Infarction/drug therapy , Streptokinase/administration & dosage , Thrombolytic Therapy , Adult , Aged , Angiotensin-Converting Enzyme Inhibitors/adverse effects , Blood Flow Velocity/drug effects , Captopril/adverse effects , Coronary Angiography/drug effects , Drug Administration Schedule , Drug Therapy, Combination , Electrocardiography/drug effects , Female , Follow-Up Studies , Humans , Male , Middle Aged , Myocardial Infarction/mortality , Regional Blood Flow/drug effects , Streptokinase/adverse effects , Stroke Volume/drug effects , Survival Rate
7.
Am J Cardiol ; 81(6): 665-71, 1998 Mar 15.
Article in English | MEDLINE | ID: mdl-9527071

ABSTRACT

Because 24% to 30% of patent infarct-related arteries occlude in the year following thrombolytic therapy for acute myocardial infarction, angiographic factors including corrected Thrombolysis in Myocardial Infarction (TIMI) frame count which may predict abnormal infarct-artery flow, require definition. We examined changes in coronary flow and infarct-artery lesion severity by computerized quantitative angiography over 1 year in 154 patients with a patent infarct-related artery 4 weeks after myocardial infarction. These patients were randomized to receive either ongoing daily therapy of 50 mg aspirin and 400 mg dipyridamole, or placebo. All angiograms were interpreted blind in our core angiographic laboratory. Infarct-artery flow, assessed by corrected TIMI frame counts, was normal (< or = 27) in 46% and 45% of patients at 4 weeks and 1 year, respectively. At 4 weeks, patients with corrected TIMI frame counts < or = 27 had higher ejection fractions (60+/-11% vs 56+/-12%; p = 0.04) than those with corrected TIMI frame counts >27. On multivariate analysis, corrected TIMI frame count and stenosis severity were predictive of late abnormal infarct-artery flow (TIMI 0 to 2 flow, both p <0.01). Only stenosis severity at 4 weeks predicted reocclusion at 1 year (p <0.0001). Aspirin and dipyridamole had no effect on flow or reocclusion. Thus, corrected TIMI frame count and stenosis severity at 4 weeks was highly correlated with infarct-artery flow at 1 year.


Subject(s)
Coronary Circulation , Coronary Disease/physiopathology , Myocardial Infarction/physiopathology , Thrombolytic Therapy , Aged , Confounding Factors, Epidemiologic , Coronary Angiography , Coronary Disease/diagnostic imaging , Disease Progression , Female , Humans , Male , Middle Aged , Multivariate Analysis , Myocardial Infarction/drug therapy , Predictive Value of Tests , Recurrence , Reproducibility of Results , Severity of Illness Index , Vascular Patency
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