Influence of time to treatment on early infarct-related artery patency after different thrombolytic regimens

Zeymer, Uwe; Tebbe, Ulrich; Essen, R. von; Haarmann, W; Neuhaus, K.-L.

doi:10.1016/s0002-8703(99)70457-6

Cited by 66 publications

(29 citation statements)

References 19 publications

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“…Differences in the time-dependence efficacy of various reperfusion regimens [3][4][5][6][7] and the fact that a sizable number of patients with AMI present relatively late after symptom onset 15,16 underscore the clinical importance of such stratification strategy. Experimental studies in dogs 17 and clinical studies in patients with AMI 18 have demonstrated the existence of residual blood flow to the infarcted area.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 Several studies have suggested a clinically important difference in the time dependence of the efficacy of various reperfusion therapies. [3][4][5][6][7] Large studies have shown that therapeutic efficacy of thrombolysis correlates closely with the time-to-treatment interval. 1,8 In the Global Utilization of Streptokinase and Tissue Plasminogen Activator for occluded Coronary Arteries (GUSTO-1) study, 30-day mortality increased from 5.5% if treatment was initiated Յ2 hours to 9% if treatment was initiated Ͼ4 hours.…”

mentioning

confidence: 99%

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Therapy-Dependent Influence of Time-to-Treatment Interval on Myocardial Salvage in Patients With Acute Myocardial Infarction Treated With Coronary Artery Stenting or Thrombolysis

et al. 2003

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Background-The relationship between myocardial salvage and time-to-treatment interval in patients with acute myocardial infarction (AMI) treated with coronary artery stenting or thrombolysis has not been studied. Methods and Results-This study analyzed 264 patients with AMI randomized to coronary stenting (133 patients) or thrombolysis (131 patients) in the setting of 2 randomized trials. Patients were divided into the following 3 groups defined by tertiles of the time-to-treatment interval: lower tertile (Ͻ165 minutes), middle tertile (165 to 280 minutes), and upper tertile (Ͼ280 minutes). Paired scintigraphic examinations were performed to obtain salvage index, which was the primary end point of the study. In the group with thrombolysis, the salvage index (median

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Therapy-Dependent Influence of Time-to-Treatment Interval on Myocardial Salvage in Patients With Acute Myocardial Infarction Treated With Coronary Artery Stenting or Thrombolysis

et al. 2003

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“…However, the fibrin-specific agent tPA administered over 3 hours or in accelerated mode and the bolus fibrinspecific agent reteplase did not show a decrease in TIMI 2/3 and TIMI 3 flow when symptom duration was 181 to 360 minutes compared with 0 to 180 minutes. 21 Thus, the data strongly suggest that at up to 6 hours of symptom duration, although nonspecific fibrinolytics like streptokinase are less effective in achieving coronary artery patency and normal flow with increasing ischemic time, this limitation does not extend to the fibrin-specific fibrinolytics. Some in vitro data exist consistent with these observations that could be explained by less effective penetration of older clots by nonfibrin-specific fibrinolytic drugs.…”

Section: Beyond 3 Hoursmentioning

confidence: 97%

“…19 Similarly, in a retrospective analysis of 2 French studies of coronary artery patency in patients receiving FT, Steg et al 20 found that when streptokinase was used (244 patients), the achievement of normal flow (TIMI 3) and TIMI 2/3 flow decreased with longer symptom duration (Ͻ3 versus Ն3 hours), whereas with tPA (237 patients), coronary artery TIMI flows 3 and 2/3 remained stable regardless of symptom duration. 20 This distinction was reinforced by Zeymer et al 21 in a retrospective analysis of 6 other angiographic trials in 1111 patients with STEMI treated with FT that examined TIMI flow relative to symptom duration that was dichotomized between 0 to 180 minutes and 181 to 360 minutes ( Table). They found that the non-fibrinspecific agents streptokinase, urokinase, and anisoylated plasminogen-streptokinase activator complex achieved significantly less TIMI 3 and TIMI 2/3 flow with longer symptom duration.…”

Section: Beyond 3 Hoursmentioning

confidence: 99%

Duration of Symptoms Is Not Always the Key Modulator of the Choice of Reperfusion for ST-Elevation Myocardial Infarction

Bogaty

2009

Circulation

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F ibrinolytic therapy (FT) and primary percutaneous coronary intervention (PCI) are both well-accepted reperfusion therapies in ST-segment elevation myocardial infarction (STEMI). The evidence of randomized clinical trials indicates a relatively modest difference in 30-day mortality (Ϸ1%) in favor of primary PCI over fibrin-specific FT and was based on very timely primary PCI (ie, a primary PCI-related delay of 40 minutes [door-to-balloon less door-to-needle time]). 1 Longer delays to primary PCI, which are far more frequent in clinical practice, 2 are associated with attenuated benefit or no benefit at all, particularly when compared with fibrin-specific FT. 3,4 The benefit of timely primary PCI over FT is likely to especially apply to higher-risk patients. 5,6 Irrespective of the method of reperfusion, the potential for myocardial salvage and better clinical outcome is inversely proportional to ischemic time or its only available clinical surrogate, symptom duration. [7][8][9][10][11][12] These considerations underpin the notion expressed in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of STEMI that timely reperfusion therapy is likely more important in determining outcome than whether FT or primary PCI is the chosen reperfusion method. 13 Response by Armstrong et al p 1310The ACC/AHA STEMI guidelines highlight the time point of 3 hours of symptom duration in guiding the choice of reperfusion therapy. They state that if symptom duration is Ͻ3 hours, no preference exists between FT and primary PCI provided that treatment is timely (for FT, door-to-needle time Ͻ30 minutes; for primary PCI, door-to-balloon time Ͻ90 minutes and Յ60 minutes between estimated needle time and estimated balloon time). However, if symptom duration exceeds 3 hours, these guidelines favor primary PCI over FT, again provided that primary PCI can be performed in a timely fashion. 13 This article reexamines the evidence that may or may not be the basis for orienting the choice of reperfusion therapy in patients with STEMI according to symptom duration. It is emphasized that this work is not intended to reopen a primary PCI versus FT, "1 size fits all" debate. It rather addresses the question of the extent to which the evidence suggests that symptom duration should modulate the choice of reperfusion therapy. Within the "Golden Hour"Within the "golden hour" for reperfusion (symptom duration Ͻ2 hours, ideally Ͻ1 hour), the slope of the relation between ischemic time and outcome is extremely steep. 8 Both experimentally and clinically, in this critical time frame, a small increment (or decrement) of time to treatment may have dramatic consequences on the quantity of irreversibly damaged myocardium and on clinical outcome. 7,8 A substantial

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“…The effectiveness of both fibrinolytic therapy and primary PCI diminishes with the passage of time 12,13 ; however, the ability of PCI to produce a patent infarct-related artery is much less timedependent.…”

mentioning

confidence: 99%

Acute Coronary Syndromes: Diagnosis and Management, Part II

Kumar

Cannon

2009

Mayo Clinic Proceedings

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). Individual reprints of this article and a bound reprint of the entire Symposium on Cardiovascular Diseases will be available for purchase from our Web site www.mayoclinicproceedings.com. 2,3 Regardless of the mode of reperfusion, the overarching concept is to minimize total ischemic time, which is defined as the time from the onset of symptoms of STEMI to the initiation of reperfusion therapy. The 2004 STEMI guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) 4 and the 2007 focused update of these guidelines 5 recommend that all patients with STEMI undergo rapid assessment for reperfusion therapy and that a reperfusion strategy be implemented promptly after the patient's contact with the medical system. The goal is to initiate fibrinolytic therapy within 30 minutes (door-toneedle time or first medical contact-to-needle time) and to achieve intracoronary balloon inflation within 90 minutes (door-to-balloon time or first medical contact-to-balloon time) of the patient's arrival at the hospital or first contact with the medical system. © 2009 Mayo Foundation for Medical Education and REPERFUSION THERAPY FibrinolysisAn overview of the results of 9 trials by the Fibrinolytic Therapy Trialists' Collaborative Group comparing the outcomes of patients undergoing fibrinolytic therapy and those of controls demonstrated statistically significant absolute reductions in 35-day mortality rates of approximately 30 per 1000 for patients who arrived at the hospital within 6 hours of the onset of symptoms and of approximately 20 per At the most severe end of the spectrum of acute coronary syndromes is ST-segment elevation myocardial infarction (STEMI), which usually occurs when a fibrin-rich thrombus completely occludes an epicardial coronary artery. The diagnosis of STEMI is based on clinical characteristics and persistent ST-segment elevation as demonstrated by 12-lead electrocardiography. Patients with STEMI should undergo rapid assessment for reperfusion therapy, and a reperfusion strategy should be implemented promptly after the patient's contact with the health care system. Two methods are currently available for establishing timely coronary reperfusion: primary percutaneous coronary intervention and fibrinolytic therapy. Percutaneous coronary intervention is the preferred method but is not always available. Antiplatelet agents and anticoagulants are critical adjuncts to reperfusion. This article summarizes the current evidence-based guidelines for the diagnosis and management of STEMI. This summary is followed by a brief discussion of the role of noninvasive stress testing in the assessment of patients with acute coronary syndrome and their selection for coronary revascularization. Proc. 2009;84(11):1021-1036 ACC = American College of Cardiology; ACE = angiotensin-converting enzyme; ACS = acute coronary syndrome; AHA = American Heart Association; APTT = activated partial thromboplastin time; ASSENT = Assessment of the Safety of a New Thrombolytic; CABG = coronary artery bypas...

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Influence of time to treatment on early infarct-related artery patency after different thrombolytic regimens

Cited by 66 publications

References 19 publications

Therapy-Dependent Influence of Time-to-Treatment Interval on Myocardial Salvage in Patients With Acute Myocardial Infarction Treated With Coronary Artery Stenting or Thrombolysis

Therapy-Dependent Influence of Time-to-Treatment Interval on Myocardial Salvage in Patients With Acute Myocardial Infarction Treated With Coronary Artery Stenting or Thrombolysis

Duration of Symptoms Is Not Always the Key Modulator of the Choice of Reperfusion for ST-Elevation Myocardial Infarction

Acute Coronary Syndromes: Diagnosis and Management, Part II

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