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Coronary angiographic findings and troponin T in patients with unstable angina pectoris

AMERICAN JOURNAL OF CARDIOLOGY 2000年第7期85卷 810-814页

作者： Jurlander, B Farhi, ER Banas, JJ Keany, CM Balu, D Grande, P Ellis, AK Dept Vet Affairs Med Ctr Med Serv Buffalo NY USA Dept Vet Affairs Med Ctr Pathol & Lab Med Serv Buffalo NY USA Dept Vet Affairs Med Ctr Ambulatory Care Serv Buffalo NY USA SUNY Buffalo Buffalo NY 14260 USA Natl Univ Hosp Ctr Heart Rigshosp Copenhagen Denmark

This study sought to identify differences in coronary anatomic pathology in patients with unstable angina and elevated versus nonelevated serum troponin T values. Previous studies have shown a worse prognosis in unstable angina patients with elevated serum troponin T values. Consecutive patients (n = 117) with Braunwald class IIIB angina were included in the study. Serum samples for troponin T were obtained at admission and every 6 to 8 hours for 18 to 24 hours. Acute myocardial infarction was excluded by routine creatine kinase measurements. All patients underwent coronary angiography before discharge. Cardiac events including cardiac death and myocardial infarction were recorded. Two thirds of the patients with unstable angina had no increase in serum troponin T (<0.1 mu g/L) (n = 80). They had a lower incidence of 3-vessel disease (26% vs 46%, p <0.001), left main disease (5% vs 16%, p = 0.04), visible thrombus (4% vs 22%, p = 0.006), and less severe stenosis of the culprit artery (65% vs 84%, p <0.004) than patients with elevated serum troponin T values (greater than or equal to 0.1 mu g/L) (n = 37). The 1-year cardiac event rate was 0% versus 19% in patients with troponin T values <0.1 mu g/L compared with patients with serum troponin T values greater than or equal to 0.1 mu g/L (p <0.0001). It was concluded that patients with unstable angina and no release of troponin T have less severe coronary artery disease, and have an excellent prognosis. It is suggested that these patients may be managed more conservatively and without invasive evaluation before discharge. (C)2000 by Excerpta Medica, Inc.

关键词：心绞痛不稳定型/血液心绞痛不稳定型/并发症心绞痛不稳定型/死亡率心绞痛不稳定型/放射摄影术生物学标记/血液冠状血管造影术冠心病重症监护病房猝死心脏/流行病学猝死心脏/病因学心电描记术医院死亡率发病率心肌梗死/血液心肌梗死/流行病学心肌梗死/病因学心肌梗死/放射摄影术纽约/流行病学预后回顾性研究肌钙蛋白T/血液成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Abciximab reduces mortality in diabetics following percutaneous coronary intervention

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第4期35卷 922-928页

作者： Bhatt, DL Marso, SP Lincoff, AM Wolski, KE Ellis, SG Topol, EJ Cleveland Clin Fdn Dept Cardiol Cleveland OH 44195 USA

OBJECTIVES We sought to determine whether abciximab therapy at the time of percutaneous coronary intervention (PCI) would favorably affect one-year mortality in patients with diabetes. BACKGROUND Diabetics are known to have increased late mortality following PCI. METHODS Data from three placebo-controlled trials of PCI, EPIC, EPILOG, and EPISTENT, were pooled. The one-year mortality rate for patients with a clinical diagnosis of diabetes mellitus was compared with the rate for nondiabetic patients treated with either abciximab or placebo. RESULTS In the 1,462 diabetic patients, abciximab decreased the mortality from 4.5% to 2.5%, p = 0.031, and in the 5,072 nondiabetic patients, from 2.6% to 1.9%, p = 0.099. In patients with the clinical syndrome of insulin resistance-defined as diabetes, hypertension, and obesity-mortality was reduced by abciximab treatment from 5.1% to 2.3%, p = 0.044. The beneficial reduction in mortality with abciximab use in diabetics classified as insulin-requiring was from 8.1% to 4.2%, p = 0.073. Mortality in diabetics who underwent multivessel intervention was reduced from 7.7% to 0.9% with use of abciximab, p = 0.018. In a Cox proportional hazards survival model, the risk ratio for mortality with abciximab use compared with placebo was 0.642 (95% confidence interval 0.458-0.900, p = 0.010). CONCLUSIONS Abciximab decreases the mortality of diabetic patients to the level of placebo-treated nondiabetic patients. This beneficial effect is noteworthy in those diabetic patients who are also hypertensive and obese and in diabetics undergoing multivessel intervention. Besides its potential role in reducing repeat intervention for stented diabetic patients, abciximab therapy should be strongly considered in diabetic patients undergoing PCI to improve their survival. (C) 2000 by the American College of Cardiology.

关键词：心绞痛不稳定型/死亡率心绞痛不稳定型/治疗血管成形术气囊冠状动脉抗体单克隆/副作用抗体单克隆/治疗应用糖尿病血管病变/死亡率糖尿病血管病变/治疗剂量效应关系药物用药计划表随访研究免疫球蛋白Fab片段/副作用免疫球蛋白Fab片段/治疗应用心肌梗死/死亡率心肌梗死/治疗血小板聚集抑制剂/副作用血小板聚集抑制剂/治疗应用血小板糖蛋白GPⅡb-Ⅲa复合物/拮抗剂和抑制剂随机对照试验(主题) 复发危险因素支架存活率成年人老年人女(雌)性人类男(雄)性中年人

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Low molecular weight heparin decreases rebound ischemia in unstable angina or non-Q-wave myocardial infarction:: The Canadian ESSENCE ST segment monitoring substudy

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第5期36卷 1507-1513页

作者： Goodman, SG Barr, A Sobtchouk, A Cohen, M Fromell, GJ Laperrière, L Hill, C Langer, A Univ Toronto Div Cardiol Canadian Heart Res Ctr St Michaels Hosp Toronto ON M5B 1W8 Canada Hahnemann Univ Hosp Div Cardiol Philadelphia PA 19102 USA Covance Clin Trials Res & Dev Inc Princeton NJ USA Univ Montreal Hosp Ctr Dept Gen Med Montreal PQ Canada Fournier Pharma Montreal PQ Canada

OBJECTIVES The goal of this study was to determine whether enoxaparin was more effective than heparin in reducing recurrent ischemic episodes. BACKGROUND Continuous ST segment monitoring is a simple tool for assessment of ischemia and identifies patients with a worse prognosis. Little is known about the impact of low molecular weight heparin on ST segment shift. METHODS Patients were randomized to receive enoxaparin or heparin (mean 3.4 days). Three-lead ST segment monitoring was performed for the first 48 h (n = 220) and an additional 38 h (n = 174) after intravenous study drug discontinuation (mean 1.9 days later). RESULTS During initial monitoring, ischemia rates were similar among the heparin and enoxaparin groups (27.2% vs. 22.6%, p = 0.44);however, the time to first ischemic episode was earlier among heparin-treated patients (11 +/- 11 vs. 25 +/- 18 min, p = 0.001). After drug: discontinuation, ischemic episodes occurred more frequently (44.6% vs. 25.6%, p = 0.009), and the total ischemic duration was greater among heparin patients (18 +/- 39 vs. 5 +/- 12 min/24 h, p = 0.005). Recurrent ischemia occurred more frequently after discontinuation in the heparin (46% vs. 31%, p = 0.043), but not the enoxaparin, group (18.4%, vs. 25%, p = 0.33). Regardless of treatment, patients with ischemia were more likely to die or experience (re)infarction at one year (18.4% vs. 8.3%, p = 0.023). CONCLUSIONS ST segment shift occurs frequently in unstable angina/non-Q-wave myocardial infarction despite antithrombotic therapy and is associated with worse one-year prognosis. Enoxaparin is a more effective antithrombotic treatment than unfractionated heparin and leads to greater prevention of rebound ischemia. (C) 2000 by the American College of Cardiology.

关键词：心绞痛不稳定型/并发症心绞痛不稳定型/死亡率心绞痛不稳定型/病理生理学心电描记术依诺肝素/治疗应用纤维蛋白溶解药/治疗应用随访研究心肌梗死/并发症心肌梗死/死亡率心肌梗死/病理生理学心肌缺血/病因学心肌缺血/死亡率心肌缺血/预防和控制复发存活率时间因素老年人女(雌)性人类男(雄)性中年人

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Long-term prognostic value of serial troponin T bedside tests in patients with acute coronary syndromes

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第6期86卷 623-627页

作者： van Domburg, RT Cobbaert, C Kimman, GJ Zerback, R Simoons, ML Univ Hosp Rotterdam Dijkzigt Thoraxctr NL-3015 GD Rotterdam Netherlands Roche Diagnost GMBH Mannheim Germany

The early presence of troponin T in serum strongly predicts short-term mortality and myocardial infarction in patients with acute coronary syndromes. We investigated the long-term outcome of the prognostic significance of the troponin T rapid bedside assay (TROPT) and compared this with the quantitative troponin T assay (cTnT enzyme-linked immunosorbent assay), myoglobin and creatine kinase-MB (CK-MB) mass. One hundred sixty-three patients with chest pain and suspected acute coronary syndromes were studied and followed prospectively for 3 years. Serial blood specimens were obtained at admission and at 3, 6, 12, 24, 48, 72, and 96 hours after admission. Patients were classified as having acute myocardial infarction in 99 patients (61%), unstable angina in 34 patients (21%), and no evidence For acute cardiac ischemia in 30 patients (18%). At 3 years, 28 patients (17%) had died of which 25 deaths (15%) were for cardiac reasons. Twenty-one patients (13%) had a nonfatal (recurrent) myocardial infarction. At admission 29% of the patients were TROPT positive (greater than or equal to 0.2 mu g/L), another 31% became positive within 12 hours, and 39% remained negative. When adjusted for baseline variables, a positive TROPT (any sample 0 to 12 hours) was independently associated with a higher risk of cardiac mortality (RR 4.3, 95% confidence interval [CI] 1.3 to 14.0). Because troponin T stays elevated vp to 2 weeks, later TROPT results between 24 and 96 hours remained significantly predictive for mortality. The cTnT enzyme-linked immunosorbent assay (any sample 0 to 12 hours;cutoff greater than or equal to 0.2 mu g/L) was similarly predictive (RR 2.9, 95% CI 1.0 to 8.6). Early myoglobin results were significantly prognostic for cardiac mortality vp to 12 hours after admission (RR 3.7;95% CI 1.0 to 12.0). In contrast, serial CK-MB mass measurements were not predictive of mortality. Thus, a combination of a baseline TROPT and on additional TROPT 12 hours or later identifies a

关键词：急性病心绞痛不稳定型/血液心绞痛不稳定型/死亡率心绞痛不稳定型/外科学生物学标记/血液肌酸激酶/血液肌酸激酶 MB型酶联免疫吸附测定随访研究同工酶类/血液心肌梗死/血液心肌梗死/死亡率心肌梗死/外科学心肌血管重建术肌红蛋白/血液床旁诊断化验信息系统预后复发回顾性研究疾病严重程度指数存活率肌钙蛋白T/血液女(雌)性人类男(雄)性中年人

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Effects of various anticoagulant treatments on von Willebrand factor release in unstable angina

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第1期36卷 110-114页

作者： Montalescot, G Collet, JP Lison, L Choussat, R Ankri, A Vicaut, E Perlemuter, K Philippe, F Drobinski, G Thomas, D Hop La Pitie Salpetriere Dept Cardiol Paris France Hop La Pitie Salpetriere Lab Hemostasis Paris France F Widal Hosp Biophys Lab Paris France

OBJECTIVES We tested the hypothesis that different anticoagulant treatments may produce different platelet effects and von Willebrand factor (vWf) release in unstable angina. BACKGROUND The early increase of vWf has been reported to be a risk factor for adverse outcome in unstable angina. Anticoagulant drugs play a key role in stabilization of unstable angina, but they may not have the same efficacy and the same effects on acute vWf release. METHODS We studied 154 patients enrolled in several clinical trials testing four different anticoagulant treatments in unstable angina or non-Q-wave myocardial infarction. Patients were treated during at least 48 h by either intravenous unfractionated heparin, one of two different low molecular weight heparins (enoxaparin or dalteparin) or the direct thrombin inhibitor PEG-hirudin. All patients received aspirin but no IIb/IIIa inhibitors. RESULTS The release of vWf over the first 48 h (Delta vWf) did not relate to the baseline clinical characteristics. At 30 days of follow-up, Delta vWf was sevenfold higher in patients with an end point (death, myocardial infarction, revascularization) than in patients free of events (+53 +/- 7% vs. +7 +/- 14%, p = 0.004). The same trend was present for each component of the composite end point with the highest levels for one-month mortality(+87 +/- 32% vs. +26 +/- 8%, p = 0.09). The vWf values did not increase over 48 h in patients receiving either enoxaparin or PEG-hirudin (+10 +/- 9% and -5 +/- 20%, respectively). A serious rise of vWf was measured in unfractionated heparin-treated patients (+87 +/- 11%), which differed significantly from the enoxaparin group (p = 0.0006) and PEG-hirudin group (p < 0.0001). In dalteparin-treated patients, Delta vWf was elevated (+48 +/- 8%) and did not differ from the unfractionated heparin group (NS). CONCLUSION We confirm that, in unstable angina patients, a rise of vWf over the first 18 h is associated with an impaired outcome at 30 days. Moreover, the fou

关键词：心绞痛不稳定型/药物疗法心绞痛不稳定型/代谢心绞痛不稳定型/死亡率抗凝药/治疗应用抗凝血酶类/治疗应用阿司匹林/治疗应用血小板/药物作用达肝素/治疗应用无病生存投药途径药物疗法联合依诺肝素/治疗应用水蛭素疗法水蛭素类/类似物和衍生物心肌梗死/药物疗法心肌梗死/代谢心肌梗死/死亡率血小板聚集抑制剂/治疗应用存活率治疗结果 vonWillebrand因子/代谢老年人女(雌)性人类男(雄)性中年人

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Risk stratification in acute coronary syndromes: The need for continued vigilance in "low-risk" patients

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AMERICAN HEART JOURNAL 2002年第5期144卷 750-752页

作者： Levinsky, MJ Ohman, EM Univ N Carolina Dept Med Div Cardiol Chapel Hill NC 27599 USA

Am Heart J 2002;144:750-2.

关键词：心绞痛不稳定型/血液心绞痛不稳定型/死亡率心绞痛不稳定型/病理生理学肌酸激酶/血液肌酸激酶 MB型心电描记术同工酶类/血液心肌梗死/血液心肌梗死/死亡率心肌梗死/病理生理学肌红蛋白/分析肌红蛋白/血液预后危险性评估综合征肌钙蛋白T/血液人类

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Variation in patient management and outcomes for acute coronary syndromes in Latin America and North America:: Results from the Platelet IIb/IIIa in Unstable Angina:: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial

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AMERICAN HEART JOURNAL 2001年第3期141卷 391-401页

作者： Cohen, MG Pacchiana, CM Corbalán, R Perez, JEI Ponte, CI Oropeza, ES Diaz, R Paolasso, E Izasa, D Rodas, MA Urrutia, CE Harrington, RA Topol, EJ Califf, RM Duke Univ Clin Res Inst Durham NC USA Pontificia Univ Catolica Chile Santiago Chile Hosp Domingo Luciani Caracas Venezuela Ctr Med Nacl Siglo XXI Mexico City DF Mexico Inst Cardiovasc Rosario Rosario Argentina Clin SHAIO Bogota Colombia Med Clin Guatemala City Guatemala Hosp Militar Cent San Salvador El Salvador Cleveland Clin Cleveland OH 44106 USA

Background Although more than 9500 patients have been enrolled in molar clinical trials in Latin America, practice patterns in this region have rarely been examined. We sought to compare characteristics, resource utilization, and outcomes of patients treated For acute coronary syndromes in Latin America with those in North America. Methods The Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Theraphy Trial (PURSUIT) enrolled 10,948 patients with non-ST-segment elevation acute coronary syndromes, including 585 in Latin America and 4358 in North America. We analyzed regional differences in patient groups, treatment patterns, and outcomes and used logistic regression analysis to identify association of enrollment region and survival. Results For patients in Latin America, the length of hospital stay was significantly longer (10 [7, 15] days vs 6 [4, 9], P<.001). Angiograms, angioplasty, and bypass surgery were significantly less common in Latin America (46.2%, 17.6%, and 11.3% vs 79.4%, 33.6%, and 19.4%, P<.001). Thirty-day death/myocardial infarction was not significantly higher, although mortality alone was significantly higher (6.8% vs 3.1%, P<.001). After adjustment for baseline characteristics, enrollment in Latin America remained on independent predictor for death at 30 days (odds ratio [OR] [95% confidence interval (CI)] 2.42 [1.60-3.67]) and persisted at 6 months (OR [95% CI] 2.5 [1.8-3.4]). Conclusions Latin American patients treated for acute coronary syndromes were managed less invasively and were twice as likely as their North American counterparts to die within 6 months. This mortality difference was not explained by imbalances in baseline risk.

关键词：心绞痛不稳定型/药物疗法心绞痛不稳定型/死亡率拉丁美洲/流行病学住院时间 Logistic模型北美洲/流行病学肽类/治疗应用医师诊疗模式血小板糖蛋白GPⅡb-Ⅲa复合物/拮抗剂和抑制剂女(雌)性人类男(雄)性中年人

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Identification of patients at high risk for death and cardiac ischemic events after hospital discharge

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AMERICAN HEART JOURNAL 2002年第6期143卷 966-970页

作者： Sabatine, MS McCabe, CH Morrow, DA Giugliano, RP de Lemos, JA Cohen, M Antman, EM Braunwald, E Brigham & Womens Hosp Dept Med Div Cardiovasc TIMI Study Grp Boston MA 02115 USA Univ Texas SW Med Ctr Donald W Reynolds Cardiovasc Clin Res Ctr Dallas TX USA Med Coll Penn & Hahnemann Univ Sch Med Dept Med Div Cardiol Philadelphia PA 19102 USA

Background Patients with unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI) remain at risk for death and cardiac ischemic events after being discharged from the hospital. Methods We examined whether the Thrombolysis In Myocardial Infarction (TIMI) risk score for UA/NSTEMI, ascertained at presentation in patients enrolled in the TIMI 11 B and Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and Non-Q-Wave MI (ESSENCE) trials, could be used to identify patients at high risk for major cardiac events after hospital discharge. Results There were a total of 1218 major cardiac events, defined as death, nonfatal myocardial infarction, or urgent revascularization, by day 43. Of these events, 336 (28%) occurred in patients after they were discharged from the hospital. Use of the TIMI risk score for UA/NSTEMI revealed a progressive, statistically significant increase in the rate of events after leaving the hospital as the patients' baseline level of risk increased (P < .001 for chi(2) test for trend). For patients with a risk score of 5 to 7, treatment with enoxaparin during the acute phase was associated with an odds ratio of 0.51 (95% Cl 0.29-0.91) for the occurrence of death and cardiac ischemic events after hospital discharge. Conclusions More than one fourth of the major cardiac events that will occur in the first 6 weeks occur after discharge from the hospital. Stratification at presentation on the basis of the TIMI risk score for UA/NSTEMl can be used to identify patients at high risk for these events. Among patients at high-risk, acute-phase treatment with enoxaparin significantly reduces the risk of major cardiac events after leaving the hospital.

关键词：心绞痛不稳定型/并发症心绞痛不稳定型/死亡率心绞痛不稳定型/治疗抗凝药/治疗应用依诺肝素/治疗应用纤维蛋白溶解药/治疗应用肝素/治疗应用心肌梗死/并发症心肌梗死/死亡率心肌梗死/治疗心肌血管重建术比值比病人出院危险性评估疾病严重程度指数人类

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Aggressive versus conservative therapy in unstable angina

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Cardiology Clinics 1999年第2期17卷 387-399页

作者： Lange, R.A. Hillis, L.D. Texas Univ. Southwestern Med. Ctr. Dallas TX 75235-9047 5323 Harry Hines Boulevard United States

In patients with unstable angina, non-Q-wave, and Q-wave myocardial infarction, atherosclerotic plaque rupture leads to a variable amount of platelet adhesion and aggregation, vasoconstriction, and partially or totally occlusive thrombus formation. This article focuses on the role of aggressive (routine angiography and revascularization) versus conservative (maximal medical therapy, with catheterization and revascularization reserved for those with spontaneous or provable ischemia) management of the patient with unstable angina.

关键词：心绞痛不稳定型/血液心绞痛不稳定型/死亡率心绞痛不稳定型/放射摄影术心绞痛不稳定型/治疗血管成形术经腔经皮冠状动脉冠状血管造影术预后存活率血栓溶解疗法治疗结果肌钙蛋白I/血液人类

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Predictors of recurrent ischemic events and death in unstable coronary artery disease after treatment with combination antithrombotic therapy

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AMERICAN HEART JOURNAL 2000年第6期139卷 962-970页

作者： Cohen, M Stinnett, SS Weatherley, BD Gurfinkel, EP Fromell, GJ Goodman, SG Fox, KAA Califf, RM Med Coll Penn & Hahnemann Univ Sch Med Div Cardiol Philadelphia PA 19102 USA Duke Clin Res Inst Durham NC USA Inst Cardiol & Cirug Buenos Aires DF Argentina Rhone Poulenc Rorer Collegeville PA USA St Michaels Hosp Canadian Heart Res Ctr Toronto ON M5B 1W8 Canada Royal Infirm Edinburgh Midlothian Scotland

Background Patients with non-Q-wave acute coronary syndromes (ACS) have substantial rates of recurrent ischemic events, but prognostic studies have been small or preceded the routine use of aggressive combination antithrombotic therapy. We sought to identify predictors of these events after antithrombotic treatment of non-Q-wave ACS. Methods We assessed 30-day rates of a composite triple end point (death, infarction, or refractory angina) and double end point (death or infarction) among 3171 patients with non-ST-segment elevation ACS randomly assigned to enoxaparin or heparin, plus aspirin, for 2 to 8 days. We created multivariable regression models to predict these end points from baseline factors. Results Overall, 682 patients (21%) reached the triple end point and 220 (6.8%) reached the double end point. Independent predictors of the triple end point were admission with myocardial necrosis, ST-segment depression, prior angina severity, symptom duration, and allocation to enoxaparin treatment in patients with ST-segment depression (significant interaction). independent predictors of the double end point were admission with myocardial necrosis, ST-segment depression, enrollment region, age >75 years, prior angina severity, and rales. By deciles, the average predicted risk for the double end point ranged from 2% to 20%. a patient aged <75 years with no risk factors had a 3.5% risk, whereas a patient aged >75 years with 2 additional high-risk features (myonecrosis and ST depression) had a risk of death or reinfarction of 26%. Conclusions Patients with non-ST-segment elevation ACS exhibit a broad range of risk of adverse recurrent ischemic events. The predictive power of the model for the triple end point, using baseline variables, was modest. However, a subgroup at very low risk of the double end point (average 2%) can be identified with baseline variables.

关键词：心绞痛不稳定型/药物疗法心绞痛不稳定型/死亡率阿司匹林/投药和剂量阿司匹林/治疗应用投药途径药物疗法联合心电描记术/药物作用依诺肝素/投药和剂量依诺肝素/治疗应用纤维蛋白溶解药/投药和剂量纤维蛋白溶解药/治疗应用肝素/投药和剂量肝素/治疗应用心肌缺血/药物疗法心肌缺血/死亡率预后复发疾病严重程度指数存活率老年人女(雌)性人类男(雄)性中年人

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