The late open artery hypothesis—A decade later

Sadanandan, Saihari; Buller, Christopher E.; Menon, Venu; Džavík, Vladimir; Terrin, Michael; Thompson, Bruce; Lamas, Gervasio A.; Hochman, Judith S.

doi:10.1067/mhj.2001.117774

Cited by 51 publications

(29 citation statements)

References 59 publications

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“…When initiated 2 h to 12 h after symptom onset, myocardial injury is irreversible and manifests as coagulation necrosis, with the wavefront phenomenon of extension from central ischemic myocardium toward peripheral at-risk myocardium (47). In contrast with the early phase, mortality and myocardial salvage are influenced by time-independent (or 'less dependent') effects of reperfusion therapy, collateral circulation, ischemic preconditioning and myocardial oxygen demand (41,48). Moreover, reperfusion therapy may be associated with adverse effects such as contraction band necrosis (caused by rapid influx of calcium into dying cells), reperfusion injury, intramural hemorrhage, iatrogenic coronary artery dissection and distal microvascular embolization (49,50).…”

Section: Timing Of Fibrinolysis and Subsequent Pcimentioning

confidence: 99%

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Afilalo

Roy

Eisenberg

2009

Canadian Journal of Cardiology

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P rimary percutaneous coronary intervention (PCI) has been shown to be superior to fibrinolytic therapy for the treatment of ST segment elevation myocardial infarction (STEMI) (1). However, primary PCI is suboptimal when there are prolonged delays for interhospital transfer or resource mobilization. Facilitated PCI is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors while waiting for PCI. The rationale is to open infarctrelated arteries (IRAs) as soon as possible, minimize myocardial ischemia time and, thus, salvage at-risk myocardium. Despite the theoretical benefits, randomized controlled trials have failed to support the clinical benefits of this strategy. These trials varied substantially in terms of facilitating regimens, timing of fibrinolysis, timing of PCI, and coadministered antiplatelet or antithrombin therapies. A recent metaanalysis (2) showed that facilitated PCI was associated with increased short-term mortality, reinfarction, major bleeding and stroke. Although the results of this meta-analysis were unequivocally negative, a systematic review may be better suited to address these heterogeneous and complex trials. Our objective was to systematically review trials of fibrinolytic-facilitated versus nonfacilitated PCI, and determine when this strategy may be beneficial and deserving of further research. BACKGROUND: Facilitated percutaneous coronary intervention (PCI) is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors to minimize myocardial ischemia time while waiting for PCI. A pooled meta-analysis suggested that facilitated PCI was associated with higher rates of mortality and morbidity compared with nonfacilitated PCI. OBJECTIVE: The heterogeneous and complex trials of facilitated PCI were systematically reviewed to identify where this strategy may be beneficial and deserving of further research. METHODS: MEDLINE, EMBASE, the Cochrane database, the Internet and conference proceedings were searched to obtain relevant trials. Human studies that randomly assigned patients to fibrinolytic-facilitated PCI (administration of fibrinolytic therapy alone or in combination with GP IIb/IIIa inhibitors before angiography) versus nonfacilitated PCI were included. RESULTS: Nine trials encompassing 3836 patients were reviewed. The facilitated PCI strategy was fibrinolytic therapy alone in seven trials and half-dose fibrinolytic therapy plus GP IIb/IIIa inhibitors in two trials. In patients who had fibrinolysis less than 2 h after symptom onset (mainly in the prehospital setting) and/or slightly delayed PCI 3 h to 24 h after fibrinolysis, facilitated PCI was associated with the greatest Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow and a trend toward reduced mortality. Overall, facilitated PCI was associated with increased intracranial hemorrhage and reinfarction. Combining half-dose fibrinolytic therapy and GP IIb/IIIa inhibitors reduced reinfarction but increased major bleeding. CONCLUSIONS: Facilitat...

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Section: Timing Of Fibrinolysis and Subsequent Pcimentioning

confidence: 99%

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Afilalo

Roy

Eisenberg

2009

Canadian Journal of Cardiology

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“…14 A significant proportion of patients after AMI will develop a persistently occluded infarct-related artery, with the frequency of total occlusion depending on the timing and type of reperfusion therapy (thrombolysis versus primary angioplasty versus none), as well as the time interval to patency assessment. 15 In patients with ST-segment elevation AMI not treated with reperfusion therapy, an occluded infarct-related artery has been found in 87% of patients within 4 hours, 65% within 12 to 24 hours, 53% at 15 days, and 45% at 1 month. 16 -18 As many as 30% of patients treated with thrombolytic therapy followed by conservative care have a chronically occluded artery 3 to 6 months after AMI.…”

Section: Prevalence In the Population And In Patients Undergoing Angimentioning

confidence: 99%

Percutaneous Recanalization of Chronically Occluded Coronary Arteries

et al. 2005

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R emarkable progress in the percutaneous management of coronary artery disease has been achieved over the last decade. The scaffolding properties of coronary stents have resulted in percutaneous coronary intervention (PCI) becoming a predictable procedure, with reduced rates of acute closure and late restenosis compared with balloon angioplasty alone. 1,2 More recently, the site-specific delivery of antiproliferative agents from drug-eluting stents has been demonstrated to markedly attenuate vascular responses leading to neointimal hyperplasia, further reducing the occurrence of clinical and angiographic restenosis to Ͻ10% in most patients. 3,4 PCI in patients with acute coronary syndromes and acute myocardial infarction (AMI) has also been proven to save lives, reduce rates of myocardial infarction (MI), and enhance quality of life compared with alternative treatment modalities. [5][6][7] With these advances in perspective, it is often stated that successful recanalization of chronic total occlusions (CTOs) of native coronary arteries represents the "last frontier" of PCI. This statement is made in deference to the fact that CTOs represent the most technically challenging lesion subset that interventional cardiologists face, with procedural success rates considerably lower than those achieved in nonoccluded coronary vessels or acutely occluded arteries. Moreover, no consensus exists with regard to the definition of CTO, the factors related to procedural failure and/or complications, and the optimal technical approach. Indeed, until recently, the clinical benefits of PCI in CTOs had not been demonstrated.An international panel of 47 physicians from 9 countries was therefore convened in New York City for 2 days in January 2004, the purpose of which was to reach consensus on the current state of the art of CTO angioplasty (see Appendix in the online-only Data Supplement for a complete participant list). This goal was approached through a series of didactic lectures, roundtable discussions, breakout focus groups, and the performance of 14 live case demonstrations of CTO angioplasty by many of the world's most skilled operators in this subspecialty. The present report represents a synthesis of the findings from this meeting and also incorporates a literature review from the field of CTO intervention. Topics covered in Part I of this review include definitions, prevalence, and clinical presentation of CTOs; the anatomy and histopathology of coronary occlusions; experimental CTO models; and the clinical relevance and rationale for CTO revascularization. Part II will review the technical approach to and clinical outcomes after percutaneous intervention of CTOs and describe the novel devices and drugs approved and undergoing investigation for CTO recanalization.

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“…The benefit of even later (Ͼ48 hours) opening of an occluded infarct artery is under investigation in the ongoing Occluded Artery Trial (OAT). 21 …”

Section: A Rational Approach To Reperfusion Therapymentioning

confidence: 99%

Selecting the Best Reperfusion Strategy in ST-Elevation Myocardial Infarction

Giugliano

Braunwald

2003

Circulation

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T he primary goal of treatment of acute coronary occlusion is the achievement of early, complete, and sustained epicardial and myocardial reperfusion. Fibrinolytic therapy was first attempted in 1958, 1 and, until recently, constituted the dominant approach for reperfusion. Primary coronary intervention (PCI) is now being used as an alternative to fibrinolysis with increasing frequency. This approach is supported by a recent comprehensive meta-analysis of 23 trials that demonstrated reductions in death, recurrent myocardial infarction, and stroke of 2, 4, and 1 per 100 patients treated through 30 days, respectively. 2 Attempts to improve the efficacy of the standard pharmacological reperfusion regimen consisting of aspirin, unfractionated heparin, and front-loaded tissue plasminogen activator using more fibrin specific fibrinolytic agents, bolus preparations, more potent antithrombotic drugs, and platelet glycoprotein IIb/IIIa inhibitors have not reduced mortality. 3 In contrast, a meta-analysis of clinical trials that compared prehospital fibrinolysis to hospital administration demonstrated a 17% relative reduction in mortality when time to treatment was reduced by an average of 1 hour. 4

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The late open artery hypothesis—A decade later

Cited by 51 publications

References 59 publications

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Percutaneous Recanalization of Chronically Occluded Coronary Arteries

Selecting the Best Reperfusion Strategy in ST-Elevation Myocardial Infarction

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