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Implications of the Organization to Assess Strategies for Ischemic Syndromes-2 (OASIS-2) study and the results in the context of other trials

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第5A期84卷 26M-31M页

作者： Fox, KAA Royal Infirm Edinburgh NHS Trust Cardiovasc Res Unit Edinburgh EH3 9YW Midlothian Scotland

Although unfractionated heparin is widely used for thrombin inhibition in the management of unstable coronary artery disease, clinical and experimental evidence suggests that it is suboptimal. Recent pharmaceutical strategies to improve upon unfractionated heparin's efficacy profile have centered on the development of 2 major classifications of thrombin inhibition medications: the naturally occurring leech protein hirudin (and synthetic analogs) and low-molecular-weight (LMW) heparins. In the Organisation to Assess Strategies for Ischaemic Syndromes-2 (OASIS-2) trial, hirudin was demonstrably more effective than heparin in diminishing rates of death, myocardial infarction (MI), and angina at both 72 hours and 7 days after unstable coronary artery disease index events, with risk ratios on the order of 0.8. Similarly, in the Efficacy and Safety of Subcutaneous Enoxaparin in Nan-Q-Wave Coronary Events (ESSENCE) study, the LMW heparin enoxaparin emerged superior to unfractionated heparin in attenuating rates of unstable coronary artery disease at 14 days, 30 days, and 1 year. On the other hand, findings involving other LMW heparins (dalteparin sodium, Fragmin, and fraxaparin) are equivocal, Although the Fragmin During Instability in Coronary Artery Disease (FRISC) study demonstrated statistically significant superiority of this LMW heparin over aspirin/placebo in driving down death/ Ml/revascularization rates, the Fragmin in Unstable Coronary Artery Disease (FRIC) trial showed no such superiority, but had wide confidence intervals. Similarly, the Fraxaparin Versus Unfractionated Heparin in Acute Coronary Syndromes (FRAXIS) trial with fraxaparin failed to show superiority over unfractionated heparin. The favorable efficacy findings associated with hirudin and enoxaparin regimens, compared with unfractionated heparin, accrued without significant increases in the incidences of life-threatening bleeding events (e.g., hemorrhagic stroke), but did include more frequent lesser

关键词：心绞痛不稳定型/病因学心绞痛不稳定型/预防和控制抗凝药/治疗应用达肝素/治疗应用猝死心脏/病因学猝死心脏/预防和控制依诺肝素/治疗应用肝素/治疗应用肝素低分子量/治疗应用水蛭素疗法心肌梗死/病因学心肌梗死/预防和控制心肌缺血/并发症心肌缺血/药物疗法心肌缺血/代谢血小板糖蛋白GPⅠb-Ⅸ复合物血小板膜糖蛋白类受体细胞表面/拮抗剂和抑制剂登记危险治疗结果人类

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Prediction of cardiac events after uncomplicated acute myocardial infarction by clinical variables and dobutamine stress test

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第2期34卷 435-440页

作者： Salustri, A Ciavatti, M Seccareccia, F Palamara, A Hosp Sandro Pertini Div Cardiol I-00157 Rome Italy Ist Super Sanita Epidemiol & Biostat Lab I-00161 Rome Italy

OBJECTIVES We sought to determine the relative prognostic power of several clinical and dobutamine stress test variables in patients after a first uncomplicated acute myocardial infarction (AMI). BACKGROUND The value of dobutamine echocardiography (DE) for determining prognosis after AMI is not yet defined. In particular, the influence of dobutamine stress test response on the outcome of these patients is unknown. METHODS A graded predischarge DE (from 5 to 40 mu g/kg/min, plus atropine if needed) was performed in 245 patients (mean age 60 +/- 10 years) with a first uncomplicated AMI. RESULTS At follow-up (17 +/- 13 months), an adverse outcome occurred in 40 patients: cardiac death in 7, nonfatal myocardial infarction in 9 (hard events = 16) and unstable angina requiring hospital readmission in 24. Significant predictors of adverse outcome by univariate analysis were positive DE, ischemic wall motion score index (WMSI), angina during DE and diabetes for all events, and positive DE, ischemic WMSI and age for hard events. At multivariate analysis, the only independent predictors of adverse outcome were positive DE, diabetes and angina during DE for all events, and positive DE and age for hard events. The presence of both age >60 years and a history of diabetes identified patients at high risk of cardiac events (event rate 37%), compared with patients <60 years and no diabetes (event rate 11%). In patients with intermediate risk (only one clinical risk factor, event rate 18%), DE added prognostic information (event rate 10% in the negatives, 25% in the positives and 35% in the positives with angina). CONCLUSIONS After uncomplicated AMI, dobutamine stress test variables offer additional prognostic information to clinical data. (C) 1999 by the American College of Cardiology.

关键词：心绞痛不稳定型/病因学强心药猝死/病因学多巴酚丁胺超声心动描记术心肌梗死/并发症心肌梗死/诊断显像心肌梗死/死亡率试验预期值预后前瞻性研究复发女(雌)性人类男(雄)性中年人

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Reoperative revascularization of a left internal mammary artery ostial stenosis

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ANNALS OF THORACIC SURGERY 2000年第3期70卷 963-964页

作者： Nguyen, DQ Bolman, RM Park, SJ Univ Minnesota Hosp & Clin Div Thorac & Cardiovasc Surg Minneapolis MN 55455 USA

A severe ostial stenosis of the left internal mammary artery graft was responsible for unstable angina in a patient with a previous coronary artery bypass graft. Successful revascularization of the lesion was achieved with a subclavian artery-to-left internal mammary artery bypass using a saphenous vein conduit. This procedure was performed through a left thoracotomy incision to avoid potential hazards of a redo median sternotomy. (Ann Thorac Surg 2000;70:963-4) (C) 2000 by The Society of Thoracic Surgeons.

关键词：心绞痛不稳定型/病因学冠状动脉分流术乳房动脉/外科学心肌血管重建术/方法再手术锁骨下动脉/外科学胸廓切开术人类男(雄)性中年人

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Reappraising the role of immediate intervention following thrombolytic recanalization in acute myocardial infarction

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第4期86卷 400-405页

作者： Grech, ED Sutton, AGC Campbell, PG Ashton, VJ Price, DJA Hall, JA de Belder, MA S Cleveland Hosp Cardiothorac Div Dept Cardiol Middlesbrough TS4 3BW Cleveland England Univ Teesside Ctr Hlth & Med Res Middlesbrough Cleveland England

Early studies indicated that after successful thrombolytic recanalization, adjunctive percutaneous transluminal coronary angioplasty (PTCA) was not appropriate, even when a significant residual stenosis was present. The aim of this study was to assess in-hospital clinical outcomes of patients with acute myocardial infarction (AMI) who underwent successful recanalization after thrombolytic therapy. The relation between repeat AMI/unstable angina and the severity of the stenosis, as well as other angiographic and clinical features was also examined. One hundred patients with AMI of <10 hours underwent coronary angiography 2 hours after receiving thrombolytic therapy. Salvage PTCA +/- stenting was performed if recanalization was unsuccessful (Thrombolysis In Myocardial Infarction [TIMI] trial grade 0 to 2), and no PTCA was undertaken if there was brisk anterograde flow (TIMI 3). Angiographic analysis was performed to assess the severity of the residual lesion, as well as the presence or absence of thrombus. Forty patients had unsuccessful recanalization, and of these, 36 underwent attempted PTCA. Of the 60 patients with TIMI 3 flow, 15 required repeat angiography and PTCA after repeat AMI (n = 13) or unstable angina (n = 2) within 5 days. Receiver-operating characteristic analysis indicated an optimum percent diameter stenosis predictor of 85% for repeat AMI/unstable angina. There was no additional relation to age, gender, time to thrombolysis, the infarct-related artery, or the presence of culprit lesion thrombus. After recanalization, a high-grade stenosis >85% is common (n = 25, 42.4%). This is associated with a 54% repeat AMI/unstable angina risk-a ninefold increase in the incidence of such events than in patients with lesions <85%. Thus, patients with narrowings >85% may benefit from early intervention rather than a conservative approach. Narrowings <85% have a 94% probability of no repeat AMI/unstable angina and do not require early intervention. (C)2000 by Excer

关键词：心绞痛不稳定型/病因学血管成形术经腔经皮冠状动脉综合疗法冠状血管造影术冠心病/分类冠心病/病理学纤维蛋白溶解药/治疗应用心肌梗死/药物疗法心肌梗死/治疗前瞻性研究 ROC曲线复发危险因素链激酶/治疗应用治疗结果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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An unusual cause of shock in a woman with chest pain

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HOSPITAL PRACTICE 1999年第4期34卷 155-+页

作者： Alberio, L Fiori, G Domenighetti, G Reg Hosp La Carita Multidisciplinary Intens Care Unit Locarno Switzerland

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关键词：心绞痛不稳定型/并发症心绞痛不稳定型/药物疗法心绞痛不稳定型/病因学心血管药物/治疗应用心室/药物作用心室/病理生理学肥大左心室/并发症休克心原性/化学诱导休克心原性/药物疗法室性流出道阻塞/并发症室性流出道阻塞/病因学室性流出道阻塞/病理生理学女(雌)性人类中年人

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A comparison of troponin T and troponin I as predictors of cardiac events in patients undergoing chronic dialysis at a veteran's hospital: A pilot study

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第2期34卷 448-454页

作者： Roppolo, LP Fitzgerald, R Dillow, J Ziegler, T Rice, M Maisel, A Vet Affairs Med Ctr Dept Med Div Cardiol & Nephrol San Diego CA 92161 USA Vet Affairs Med Ctr Dept Pathol San Diego CA 92161 USA Univ Calif San Diego San Diego CA 92103 USA

OBJECTIVES The purpose of this study was to prospectively evaluate the usefulness of the cardiac troponins as predictors of subsequent cardiac events in patients with chronic renal failure undergoing dialysis. BACKGROUND Cardiac troponin T (cTnT) and I (cTnI) are cardiac markers that are specific for cardiac muscle. They are also excellent prognostic indicators for patients presenting with chest pain. Although cardiac disease is the leading cause of death in dialysis patients, standard methods to diagnose acute coronary syndromes in patients with renal failure are often misleading. METHODS A six-month prospective study was done in a university-affiliated Veterans Hospital's dialysis clinic. Forty-nine patients undergoing chronic dialysis with no complaints of chest pain were followed for cardiac events occurring in the six months after cardiac troponin measurements. These included unstable angina, acute myocardial infarction and cardiac death. An additional 83 patients with renal failure but who were not undergoing dialysis were also examined. RESULTS Within six months all three dialysis patients with elevated cTnI at entry into the study suffered an adverse complication (specificity and positive predictive value = 100%). Twenty-five patients had cTnT elevated at >0.10 ng/ml (53%). Patients with diabetes were more likely to have elevated troponin T levels (64% vs. 25%, p = 0.01), hll six patients developing cardiac events within three months had elevations of cTnT >0.1 ng/ml (sensitivity = 100%). Whereas the specificity of cTnT was only 56% for a near-term cardiac event, the negative predictive value of cTnT using a cutoff of less than or equal to 0.1 ng/ml was 100%. On restratifying patients using a cutoff value of cTnT of >0.2 ng/ml, only nine of 49 dialysis patients (18%) had elevated levels. In patients with renal failure not undergoing dialysis, only three of 83 (4%) had elevated troponin I or T. None of these patients suffered a cardiac Event in the next six m

关键词：心绞痛不稳定型/诊断心绞痛不稳定型/病因学冠心病/诊断冠心病/病因学肌酸激酶/血液猝死心脏同工酶类肾功能衰竭慢性/并发症肾功能衰竭慢性/治疗心肌梗死/诊断心肌梗死/病因学试点项目试验预期值前瞻性研究肾透析危险因素敏感性与特异性肌钙蛋白I/血液肌钙蛋白T/血液人类中年人

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The Organization to Assess Strategies for Ischemic Syndromes (OASIS) pilot study: Evaluation of acute and long-term therapies for patients with acute coronary syndromes without ST elevation

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第5A期84卷 13M-19M页

作者： Anand, SS McMaster Univ Dept Prevent Cardiol & Therapeut Hamilton ON Canada

The objectives of the Organization to Assess Strategies for Ischemic Syndromes (OASIS) Pilot Study (phase 2) were (1) to compare the efficacy, safety, and feasibility of recombinant hirudin versus unfractionated heparin as short-term therapy in patients with acute coronary syndromes without ST elevation and (2) to compare the efficacy and safety of long-term therapy with warfarin and aspirin versus standard therapy with aspirin alone in the same patient population, Investigators at 31 Canadian centers randomized 909 patients to receive either medium-dose hirudin, low-dose hirudin, or unfractionated heparin, The incidence of the 7-day primary composite outcome of cardiovascular death, new myocardial infarction (MI), or refractory angina was significantly tower among patients who received hirudin than among those assigned to unfractionated heparin, A subset of these patients was subsequently randomized to long-term, low-intensity (international normalized ratio [INR] <1.5) or moderate-intensity (INR 2-2.5) anticoagulant treatment with warfarin or to standard therapy. In this substudy, promising results were observed in favor of moderate-intensity warfarin. These findings provided the rationale for the design and conduct of the large-scale, phase III OASIS-2 trial. (C) 1999 by Excerpta Medico, Inc.

关键词：急性病心绞痛不稳定型/病因学心绞痛不稳定型/预防和控制抗凝药/治疗应用阿司匹林/治疗应用加拿大猝死心脏/病因学猝死心脏/预防和控制剂量效应关系药物用药计划表药物疗法联合心电描记术可行性研究纤维蛋白溶解药/治疗应用肝素/治疗应用水蛭素疗法心肌梗死/病因学心肌梗死/预防和控制心肌缺血/并发症心肌缺血/药物疗法心肌缺血/病理生理学试点项目重组蛋白质类/治疗应用复发登记治疗结果华法林/治疗应用老年人女(雌)性人类男(雄)性中年人

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Obesity does not influence electrocardiographic parameters in coronary patients

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第1期85卷 106-+页

作者： Nomura, A Zareba, W Moss, AJ Univ Rochester Cardiol Unit Dept Med Sch Med & Dent Rochester NY 14642 USA

Although elevated body mass index (BMI) was found to be associated with QT prolongation in healthy subjects, electrocardiographic findings in coronary patients in relation to BMI have not been investigated. We studied 936 coronary patients whose electrocardiographic parameters were compared according to their BMI and found that BMI did not affect the overall QT duration, but QT dispersion was significantly higher in normal-weight coronary patients than in obese patients.

关键词：方差分析心绞痛不稳定型/诊断心绞痛不稳定型/病因学偏倚(流行病学) 人体质量指数病例对照研究卡方分布心电描记术/标准心率 Logistic模型心肌梗死/诊断心肌梗死/病因学肥胖症/分类肥胖症/并发症肥胖症/诊断肥胖症/病理生理学危险因素女(雌)性人类男(雄)性中年人

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Incidence and risk factors predictive of unstable angina resulting from restenosis after percutaneous angioplasty of saphenous vein grafts

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AMERICAN HEART JOURNAL 2000年第6期140卷 827-833页

作者： Chandrasekar, B Bourassa, MG Montreal Heart Inst Res Ctr Montreal PQ H1T 1C8 Canada Vijaya Heart Fdn Vijaya Hosp Chennai India

Background The current study was designed to determine the incidence and risk factors for unstable angina resulting from restenosis in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) of saphenous vein graft (SVG), about which little data ore available. Methods and Results A retrospective analysis of a consecutive series of 212 patients undergoing PTCA of SVG was performed. Procedural success was achieved in 200 patients (94.3%) who formed the study group. During a follow-up of 16.8 +/- 10.2 months, 24.5% of patients presented with unstable angina resulting from restenosis. There was a higher prevalence of dyslipidemia (81.6% vs 51.2%, P<.0002) and greeter postprocedural residual stenosis (14.2% +/- 12.6% vs 7.1% +/- 11.0%, P =.007) in patients with unstable angina caused by restenosis compared with the remaining patient population. By multivariate analysis, dyslipidemia (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.64-8.39, P<.002) and to a lesser extent postprocedural residual stenosis (OR 1.04, 95% CI 1.01-1.07, P<.05) were predictive of unstable angina resulting from restenosis. Among dyslipidemic patients, those not on lipid-lowering drugs during the index procedure had a significantly higher incidence of unstable angina caused by restenosis than did those on lipid-lowering drugs (P<.05). Conclusion Unstable angina caused by restenosis presents in as many as ore fourth of patients undergoing PTCA of SVG, Dyslipidemia strongly, and to a lesser extent postprocedural residual stenosis, predicts its occurrence, Scrupulous attention to these modifiable risk factors may help reduce the incidence of unstable angina after SVG angioplasty.

关键词：心绞痛不稳定型/流行病学心绞痛不稳定型/病因学心绞痛不稳定型/治疗血管成形术经腔经皮冠状动脉降血脂药/治疗应用移植物闭塞血管/并发症移植物闭塞血管/流行病学高脂血症/并发症高脂血症/药物疗法高脂血症/流行病学发病率比值比预后魁北克/流行病学复发回顾性研究危险因素隐静脉/移植治疗失败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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Prodromal unstable angina in acute myocardial infarction: Prognostic value of short- and long-term outcome and predictor of infarct size

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AMERICAN HEART JOURNAL 2000年第1期140卷 126-133页

作者： Bahr, RD Leino, EV Christenson, RH Univ Maryland Med Syst Dept Pathol Baltimore MD 21201 USA St Agnes Healthcare Paul Dudley White Coronary Care Syst Baltimore MD USA Amer Coll Hlth Assoc Baltimore MD USA

Background An estimated 50% of patients with myocardial infarction have prodromal unstable angina. There is controversy over whether prodromal unstable angina identifies a group of patients at lower risk of short- and long-term death and the clinical importance of recording this event. Methods of 207 patients enrolled at a single Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) site, 196 survived the 24 hours after presentation, achieved peak creatine kinase MB concentrations, and were classified as having either abrupt symptom onset or prodromal unstable angina in the 2 weeks before myocardial infarction. Creatine kinase MB peak was used to categorize infarct size as aborted myocardial infarction, minor myocardial damage, or extensive myocardial injury. Follow-up was performed at 24 hours, 30 days, year, and 5 years. Multiple variables, including prodromal unstable angina, time to treatment, age, sex, previous infarction and infarct location, were analyzed for predicting infarct size. Also, these variables plus peak creatine kinase MB level and a combined variable of prodromal unstable angina and peak creatine kinase MB level were examined for predicting survival. Results Mortality rate was 2.5% within 24 hours, 9.0% at 30 days, 13.5% at 1 year, and 27.1% at 5 years. Patients categorized as either aborted infarction or minor myocardial damage were significantly more likely to have prodromal unstable symptoms (81.3% vs 51.2%, P < .001) and better survival at each follow-up period. Prodromal presentation was the most significant predictor of infarct size category (P = .001). Five-year survival was predicted by age (P < .0001), peak creatine kinase MB level (P = .007), infarct location (P = .009), the combined variables (P = .029), and prodromal unstable angina (P = .017). Prodromal unstable angina had the highest odds ratio for 5-year survival at 3.83 (95% confidence interval 1.27-11.47). Conclusions prodro

关键词：心绞痛不稳定型/诊断心绞痛不稳定型/病因学心绞痛不稳定型/死亡率置信区间缺血预处理 Logistic模型心肌梗死/并发症心肌梗死/死亡率比值比试验预期值预后危险因素疾病严重程度指数存活率分析治疗结果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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